Provider Demographics
NPI:1336487131
Name:BRONX RIVER DENTAL P.C.
Entity Type:Organization
Organization Name:BRONX RIVER DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EZRO
Authorized Official - Middle Name:
Authorized Official - Last Name:FATTAKHOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-456-2626
Mailing Address - Street 1:3000 BRONX PARK E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-6711
Mailing Address - Country:US
Mailing Address - Phone:718-655-0075
Mailing Address - Fax:718-708-6966
Practice Address - Street 1:3000 BRONX PARK E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6711
Practice Address - Country:US
Practice Address - Phone:718-655-0075
Practice Address - Fax:718-708-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-29
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046846125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes125J00000XDental ProvidersDental TherapistGroup - Single Specialty