Provider Demographics
NPI:1164194874
Name:MY SMILES DENTAL PC
Entity Type:Organization
Organization Name:MY SMILES DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GRIGORIY
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-232-6996
Mailing Address - Street 1:2101 BAY RIDGE PKWY # C
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-5955
Mailing Address - Country:US
Mailing Address - Phone:212-332-6996
Mailing Address - Fax:
Practice Address - Street 1:2101 BAY RIDGE PKWY # C
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-5955
Practice Address - Country:US
Practice Address - Phone:212-332-6996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty