Provider Demographics
NPI:1164575478
Name:AVENUE U ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:AVENUE U ORTHODONTICS, PLLC
Other - Org Name:ORTHOCLUB PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-308-8181
Mailing Address - Street 1:15 ENGLE STREET
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2936
Mailing Address - Country:US
Mailing Address - Phone:201-308-8181
Mailing Address - Fax:888-292-7017
Practice Address - Street 1:79 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223-3554
Practice Address - Country:US
Practice Address - Phone:718-373-6707
Practice Address - Fax:888-292-7017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI207071223X0400X
1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0045063Medicaid
NY03128943Medicaid