Provider Demographics
NPI:1205229044
Name:BROOKLYN SMILE DENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:BROOKLYN SMILE DENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:HERSKOVITS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-745-3456
Mailing Address - Street 1:9412 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7301
Mailing Address - Country:US
Mailing Address - Phone:718-745-3456
Mailing Address - Fax:718-745-3205
Practice Address - Street 1:9412 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7301
Practice Address - Country:US
Practice Address - Phone:718-745-3456
Practice Address - Fax:718-745-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-17
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36187122300000X, 1223P0106X
NY467241223S0112X
NY1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty