Provider Demographics
NPI:1518297852
Name:SERENE DENTAL LLC
Entity Type:Organization
Organization Name:SERENE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALTAY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANMAMEDOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-881-5977
Mailing Address - Street 1:801 W 181ST ST
Mailing Address - Street 2:APT. 26
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-4542
Mailing Address - Country:US
Mailing Address - Phone:917-881-5977
Mailing Address - Fax:917-338-7771
Practice Address - Street 1:315 W 57TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3158
Practice Address - Country:US
Practice Address - Phone:917-338-6358
Practice Address - Fax:917-470-9486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051162261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental