Provider Demographics
NPI:1437357928
Name:NINTH AVENUE DENTAL P.C.
Entity Type:Organization
Organization Name:NINTH AVENUE DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:WEISS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-435-6858
Mailing Address - Street 1:4109 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11232-4001
Mailing Address - Country:US
Mailing Address - Phone:718-435-6858
Mailing Address - Fax:718-435-5017
Practice Address - Street 1:4109 9TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11232-4001
Practice Address - Country:US
Practice Address - Phone:718-435-6858
Practice Address - Fax:718-435-5017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037498-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00823116Medicaid
NY00823116Medicaid
NY00823116Medicaid