Provider Demographics
NPI:1558909655
Name:MOONLIGHT SMILE DENTAL PC
Entity Type:Organization
Organization Name:MOONLIGHT SMILE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HASBANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-339-7773
Mailing Address - Street 1:3064 CONEY ISLAND AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6475
Mailing Address - Country:US
Mailing Address - Phone:718-975-7364
Mailing Address - Fax:718-975-7365
Practice Address - Street 1:3064 CONEY ISLAND AVE STE 1A
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6475
Practice Address - Country:US
Practice Address - Phone:718-975-7364
Practice Address - Fax:718-975-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-19
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty