Provider Demographics
NPI:1164506028
Name:PLAZA ENDODONTIC GRP PC
Entity Type:Organization
Organization Name:PLAZA ENDODONTIC GRP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JOEL
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-377-4884
Mailing Address - Street 1:2215 HENDRICKSON STREET
Mailing Address - Street 2:PLAZA ENDODONTIC GROUP PC
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5130
Mailing Address - Country:US
Mailing Address - Phone:718-377-4884
Mailing Address - Fax:718-377-1063
Practice Address - Street 1:2215 HENDRICKSON STREET
Practice Address - Street 2:PLAZA ENDODONTIC GROUP PC
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5130
Practice Address - Country:US
Practice Address - Phone:718-377-4884
Practice Address - Fax:718-377-1063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0291561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty