Provider Demographics
NPI:1417374182
Name:W DENTAL
Entity Type:Organization
Organization Name:W DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.M.D.
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:212-939-9399
Mailing Address - Street 1:706 ST. NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031
Mailing Address - Country:US
Mailing Address - Phone:212-939-9399
Mailing Address - Fax:212-939-9366
Practice Address - Street 1:706 ST. NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10031
Practice Address - Country:US
Practice Address - Phone:212-939-9399
Practice Address - Fax:212-939-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY36042-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02578545Medicaid