Provider Demographics
NPI:1558449025
Name:COMMUNITY DENTAL CARE PC
Entity Type:Organization
Organization Name:COMMUNITY DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TATYANA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIYAZOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-282-7400
Mailing Address - Street 1:1809 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226
Mailing Address - Country:US
Mailing Address - Phone:718-282-7400
Mailing Address - Fax:718-282-7488
Practice Address - Street 1:1809 NOSTRAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226
Practice Address - Country:US
Practice Address - Phone:718-282-7400
Practice Address - Fax:718-282-7488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY068293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02321557Medicaid