Provider Demographics
NPI:1265658488
Name:TALA DENTAL CARE,P.C.
Entity Type:Organization
Organization Name:TALA DENTAL CARE,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATALIYA
Authorized Official - Middle Name:I
Authorized Official - Last Name:SAFONOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-376-1090
Mailing Address - Street 1:2211 OCEAN AVE.
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-2303
Mailing Address - Country:US
Mailing Address - Phone:718-376-1090
Mailing Address - Fax:
Practice Address - Street 1:2211 OCEAN AVE.
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-2303
Practice Address - Country:US
Practice Address - Phone:718-376-1090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TALA DENTAL CARE, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046621122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01705691Medicaid