Provider Demographics
NPI:1457320301
Name:PROFESSIONAL DENTAL OFFICE PC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL OFFICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-602-5200
Mailing Address - Street 1:1323 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221
Mailing Address - Country:US
Mailing Address - Phone:718-602-5200
Mailing Address - Fax:718-602-5200
Practice Address - Street 1:167 RIVINGTON ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002
Practice Address - Country:US
Practice Address - Phone:212-673-9367
Practice Address - Fax:212-673-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0484311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01979033Medicaid