Provider Demographics
NPI:1235285024
Name:A R ADVANCED DENTAL GROUP PC
Entity Type:Organization
Organization Name:A R ADVANCED DENTAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:IZMAILOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:845-222-3330
Mailing Address - Street 1:5C MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3516
Mailing Address - Country:US
Mailing Address - Phone:845-364-9400
Mailing Address - Fax:845-364-0284
Practice Address - Street 1:5C MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3516
Practice Address - Country:US
Practice Address - Phone:845-364-9400
Practice Address - Fax:845-364-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11713OtherDORAL LOCATION NUMBER
NY022-05-383Medicaid