Provider Demographics
NPI:1528402112
Name:ELMHURST ORTHODONTICS, PC
Entity Type:Organization
Organization Name:ELMHURST ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BALES-KOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD, CAGS
Authorized Official - Phone:617-319-4180
Mailing Address - Street 1:79-11 41ST AVE
Mailing Address - Street 2:UNIT A107
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1258
Mailing Address - Country:US
Mailing Address - Phone:718-205-2888
Mailing Address - Fax:
Practice Address - Street 1:79-11 41ST AVE
Practice Address - Street 2:UNIT A107
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1258
Practice Address - Country:US
Practice Address - Phone:718-205-2888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0553731223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty