Provider Demographics
NPI:1295009447
Name:4TH AVENUE DENTAL
Entity Type:Organization
Organization Name:4TH AVENUE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:PROF
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-439-2876
Mailing Address - Street 1:5404 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3006
Mailing Address - Country:US
Mailing Address - Phone:718-439-2876
Mailing Address - Fax:718-439-2879
Practice Address - Street 1:5404 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3006
Practice Address - Country:US
Practice Address - Phone:718-439-2876
Practice Address - Fax:718-439-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ183691223G0001X
NY0279901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty