Provider Demographics
NPI:1326301516
Name:JOHN N. KERIAZES, D.D.S., P.C.
Entity Type:Organization
Organization Name:JOHN N. KERIAZES, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:KERIAZES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-728-3262
Mailing Address - Street 1:31-10 37 AVENUE
Mailing Address - Street 2:SUITE 507
Mailing Address - City:LONG ISLAND CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11101
Mailing Address - Country:US
Mailing Address - Phone:718-728-3262
Mailing Address - Fax:718-786-6823
Practice Address - Street 1:31-10 37 AVENUE
Practice Address - Street 2:SUITE 507
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:718-728-3262
Practice Address - Fax:718-786-6823
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0423571122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02016475Medicaid