Provider Demographics
NPI:1194862953
Name:ELDRIDGE DENTAL CARE P.C.
Entity Type:Organization
Organization Name:ELDRIDGE DENTAL CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DMITRIY
Authorized Official - Middle Name:
Authorized Official - Last Name:VOLOTSENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-442-9254
Mailing Address - Street 1:1432 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2204
Mailing Address - Country:US
Mailing Address - Phone:718-442-9254
Mailing Address - Fax:718-720-9107
Practice Address - Street 1:1432 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2204
Practice Address - Country:US
Practice Address - Phone:718-442-9254
Practice Address - Fax:718-720-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0478791223G0001X
NY04199711223G0001X
NY0504101223G0001X
NY0513881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01954503Medicaid