Provider Demographics
NPI:1366673857
Name:ALLCITY COSMETIC DENTAL CARE, PC
Entity Type:Organization
Organization Name:ALLCITY COSMETIC DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-351-1222
Mailing Address - Street 1:17 WALT WHITMAN RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-3610
Mailing Address - Country:US
Mailing Address - Phone:631-351-1222
Mailing Address - Fax:
Practice Address - Street 1:17 WALT WHITMAN RD
Practice Address - Street 2:SUITE 5
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3610
Practice Address - Country:US
Practice Address - Phone:631-351-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLCITY COSMETIC DENTAL CARE, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050130261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental