Provider Demographics
NPI:1275771248
Name:SUPERIOR DENTAL
Entity Type:Organization
Organization Name:SUPERIOR DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SVETLANA
Authorized Official - Middle Name:
Authorized Official - Last Name:PONOMAREVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-329-2929
Mailing Address - Street 1:2475 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-5443
Mailing Address - Country:US
Mailing Address - Phone:718-329-2929
Mailing Address - Fax:718-329-2930
Practice Address - Street 1:2475 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-5443
Practice Address - Country:US
Practice Address - Phone:718-329-2929
Practice Address - Fax:718-329-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-29
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049663261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02224179Medicaid