Provider Demographics
NPI:1467768762
Name:ATLANTIC AVE DENTAL CARE
Entity Type:Organization
Organization Name:ATLANTIC AVE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:B
Authorized Official - Last Name:SOUFERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-792-6952
Mailing Address - Street 1:96 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-3461
Mailing Address - Country:US
Mailing Address - Phone:516-792-6952
Mailing Address - Fax:516-792-6953
Practice Address - Street 1:96 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-3461
Practice Address - Country:US
Practice Address - Phone:516-792-6952
Practice Address - Fax:516-792-6953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0500401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty