Provider Demographics
NPI:1578898177
Name:ARDEN DENTAL PC
Entity Type:Organization
Organization Name:ARDEN DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALERY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUBOVIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-948-0870
Mailing Address - Street 1:337 HAMPTON GREEN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:337 HAMPTON GREEN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-0000
Practice Address - Country:US
Practice Address - Phone:718-948-0870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-15
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02355737Medicaid