Provider Demographics
NPI:1154463016
Name:ELITE DENAL CARE P.C.
Entity Type:Organization
Organization Name:ELITE DENAL CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GAVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-699-1100
Mailing Address - Street 1:9438 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-5151
Mailing Address - Country:US
Mailing Address - Phone:718-699-1100
Mailing Address - Fax:718-699-1300
Practice Address - Street 1:9438 59TH AVE
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5151
Practice Address - Country:US
Practice Address - Phone:718-699-1100
Practice Address - Fax:718-699-1300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048412122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02647501Medicaid