Provider Demographics
NPI:1346790813
Name:LIVE WELL DENTAL SERVICES PLLC
Entity Type:Organization
Organization Name:LIVE WELL DENTAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TAVELIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-309-3961
Mailing Address - Street 1:365 BRIDGE ST APT 3O
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-3802
Mailing Address - Country:US
Mailing Address - Phone:917-309-3961
Mailing Address - Fax:
Practice Address - Street 1:86 PIERREPONT ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-2819
Practice Address - Country:US
Practice Address - Phone:718-875-8088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-09
Last Update Date:2016-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50111243261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental