Provider Demographics
NPI:1467531061
Name:EAST VILLAGE DENTAL GROUP
Entity Type:Organization
Organization Name:EAST VILLAGE DENTAL GROUP
Other - Org Name:FAMILY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-677-2510
Mailing Address - Street 1:15 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-7996
Mailing Address - Country:US
Mailing Address - Phone:212-677-2510
Mailing Address - Fax:212-228-8119
Practice Address - Street 1:15 AVENUE A
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10009-7996
Practice Address - Country:US
Practice Address - Phone:212-677-2510
Practice Address - Fax:212-228-8119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0466461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01894339Medicaid