Provider Demographics
NPI:1437372380
Name:PAVEL NIDERMAN D.D.S ATLANTIC DENTAL
Entity Type:Organization
Organization Name:PAVEL NIDERMAN D.D.S ATLANTIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NIDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-996-5996
Mailing Address - Street 1:2060 LEXINGTON AVE FL 2ND
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-1759
Mailing Address - Country:US
Mailing Address - Phone:212-996-5996
Mailing Address - Fax:212-996-0030
Practice Address - Street 1:2060 LEXINGTON AVE FRNT 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-1759
Practice Address - Country:US
Practice Address - Phone:212-996-5996
Practice Address - Fax:212-996-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044976122300000X, 1223G0001X
NY0485191223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02241298Medicaid