Provider Demographics
NPI:1306012273
Name:FGC DENTAL PC
Entity Type:Organization
Organization Name:FGC DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-463-7676
Mailing Address - Street 1:3511 FARRINGTON ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-2826
Mailing Address - Country:US
Mailing Address - Phone:718-463-7676
Mailing Address - Fax:718-886-1413
Practice Address - Street 1:3511 FARRINGTON ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-2826
Practice Address - Country:US
Practice Address - Phone:718-463-7676
Practice Address - Fax:718-886-1413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037981-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00861156Medicaid