Provider Demographics
NPI:1275830465
Name:ADVANCED DENTAL OF NEW YORK PC
Entity Type:Organization
Organization Name:ADVANCED DENTAL OF NEW YORK PC
Other - Org Name:ADVANCED DENTAL SPECIALTIES OF NY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KATAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-740-6000
Mailing Address - Street 1:197-11 HILLSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2516
Mailing Address - Country:US
Mailing Address - Phone:718-740-6000
Mailing Address - Fax:718-740-6004
Practice Address - Street 1:19711 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2126
Practice Address - Country:US
Practice Address - Phone:718-740-6000
Practice Address - Fax:718-740-6004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-24
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0545771223E0200X
NY0532531223P0300X
NY0538691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty