Provider Demographics
NPI:1417194119
Name:FLATBUSH FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:FLATBUSH FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ISAAK
Authorized Official - Middle Name:
Authorized Official - Last Name:GRINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-693-5455
Mailing Address - Street 1:789 FLATBUSH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226
Mailing Address - Country:US
Mailing Address - Phone:718-693-5455
Mailing Address - Fax:718-693-7337
Practice Address - Street 1:789 FLATBUSH AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226
Practice Address - Country:US
Practice Address - Phone:718-693-5455
Practice Address - Fax:718-693-7337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-16
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0455491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01512867Medicaid