Provider Demographics
NPI:1417325382
Name:CONCOURSE PLAZA FAMILY DENTAL LLC
Entity Type:Organization
Organization Name:CONCOURSE PLAZA FAMILY DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GODRICK
Authorized Official - Middle Name:ALLISTER
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-204-3362
Mailing Address - Street 1:230 E 161ST ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10451-3546
Mailing Address - Country:US
Mailing Address - Phone:718-992-8200
Mailing Address - Fax:718-537-4169
Practice Address - Street 1:230 E 161ST ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-3546
Practice Address - Country:US
Practice Address - Phone:718-992-8200
Practice Address - Fax:718-537-4169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052071122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02677278Medicaid