Provider Demographics
NPI:1164403093
Name:NEW YORK DENTAL LLC
Entity Type:Organization
Organization Name:NEW YORK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUKHMINDER
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:PANNU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:607-777-1340
Mailing Address - Street 1:4501 VESTAL PKWY E
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-3565
Mailing Address - Country:US
Mailing Address - Phone:607-777-1340
Mailing Address - Fax:607-777-1345
Practice Address - Street 1:4501 VESTAL PKWY E
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3565
Practice Address - Country:US
Practice Address - Phone:607-777-1340
Practice Address - Fax:607-777-1345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02121915Medicaid