Provider Demographics
NPI:1407096845
Name:CHURCH AVE ORTHODONTICS, LLC
Entity Type:Organization
Organization Name:CHURCH AVE ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-282-8222
Mailing Address - Street 1:2848 CHURCH AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-4106
Mailing Address - Country:US
Mailing Address - Phone:718-282-8222
Mailing Address - Fax:718-282-8244
Practice Address - Street 1:2848 CHURCH AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-4106
Practice Address - Country:US
Practice Address - Phone:718-282-8222
Practice Address - Fax:718-282-8244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI207071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty