Provider Demographics
NPI:1437509841
Name:DENTAL ANESTHESIA OF NEW YORK, LLC
Entity Type:Organization
Organization Name:DENTAL ANESTHESIA OF NEW YORK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST ANESTHESIOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:TA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:215-527-8768
Mailing Address - Street 1:410 W 53RD ST APT 126
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-5693
Mailing Address - Country:US
Mailing Address - Phone:215-527-8768
Mailing Address - Fax:
Practice Address - Street 1:410 W 53RD ST APT 126
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5693
Practice Address - Country:US
Practice Address - Phone:215-527-8768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0543601223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03203894Medicaid