Provider Demographics
NPI:1336487750
Name:SUNNYSIDE ORTHODONTICS
Entity Type:Organization
Organization Name:SUNNYSIDE ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JASMINE
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-433-2304
Mailing Address - Street 1:4312 43RD ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2608
Mailing Address - Country:US
Mailing Address - Phone:718-433-2304
Mailing Address - Fax:
Practice Address - Street 1:4312 43RD ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-2608
Practice Address - Country:US
Practice Address - Phone:718-433-2304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0533131-81223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02860204Medicaid