Provider Demographics
NPI:1235454208
Name:DIVINE DENTAL PC
Entity Type:Organization
Organization Name:DIVINE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:SEOKKYU
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-353-2312
Mailing Address - Street 1:4125 KISSENA BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3153
Mailing Address - Country:US
Mailing Address - Phone:718-353-2312
Mailing Address - Fax:718-321-7120
Practice Address - Street 1:4125 KISSENA BLVD STE 101
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3153
Practice Address - Country:US
Practice Address - Phone:718-353-2312
Practice Address - Fax:718-321-7120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2010-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052968-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty