Provider Demographics
NPI:1255670196
Name:BLVD PLAZA DENTAL PC
Entity Type:Organization
Organization Name:BLVD PLAZA DENTAL PC
Other - Org Name:BLVD DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:MIHALIOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-279-8202
Mailing Address - Street 1:4221 FRANCIS LEWIS BLVD
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2573
Mailing Address - Country:US
Mailing Address - Phone:718-279-8202
Mailing Address - Fax:718-279-8205
Practice Address - Street 1:4221 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-2573
Practice Address - Country:US
Practice Address - Phone:718-279-8202
Practice Address - Fax:718-279-8205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-13
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052418-1122300000X
NY05577911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty