Provider Demographics
NPI:1518439967
Name:MEDIDENTAL GROUP LLC
Entity Type:Organization
Organization Name:MEDIDENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:INOYATOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-283-2396
Mailing Address - Street 1:2246 31ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2786
Mailing Address - Country:US
Mailing Address - Phone:347-283-2396
Mailing Address - Fax:
Practice Address - Street 1:2246 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2786
Practice Address - Country:US
Practice Address - Phone:347-283-2396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental