Provider Demographics
NPI:1144568601
Name:TOOTHTIMEDENTALSTUDIOPC
Entity Type:Organization
Organization Name:TOOTHTIMEDENTALSTUDIOPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SEJAL
Authorized Official - Middle Name:U
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:515-519-8080
Mailing Address - Street 1:PO BOX 81
Mailing Address - Street 2:ALBERTSON
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-0081
Mailing Address - Country:US
Mailing Address - Phone:516-519-8080
Mailing Address - Fax:516-519-8082
Practice Address - Street 1:414 JERICHO TPKE
Practice Address - Street 2:SUIT #2
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4510
Practice Address - Country:US
Practice Address - Phone:516-519-8080
Practice Address - Fax:516-519-8082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02145619Medicaid