Provider Demographics
NPI:1518382712
Name:ILLUSTRADENT WHITE PLAINS DENTAL SERVICES PLLC
Entity Type:Organization
Organization Name:ILLUSTRADENT WHITE PLAINS DENTAL SERVICES PLLC
Other - Org Name:WESTCHESTER DENTAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-320-8247
Mailing Address - Street 1:47 MAMARONECK AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-4215
Mailing Address - Country:US
Mailing Address - Phone:914-997-4148
Mailing Address - Fax:914-997-8987
Practice Address - Street 1:47 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-4215
Practice Address - Country:US
Practice Address - Phone:914-997-4148
Practice Address - Fax:914-997-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0528581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty