Provider Demographics
NPI:1598953655
Name:UNIVERSAL DENTAL ARTS, PC
Entity Type:Organization
Organization Name:UNIVERSAL DENTAL ARTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BONET
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-393-5454
Mailing Address - Street 1:169 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237-4303
Mailing Address - Country:US
Mailing Address - Phone:646-393-5454
Mailing Address - Fax:
Practice Address - Street 1:169 WYCKOFF AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4303
Practice Address - Country:US
Practice Address - Phone:646-393-5454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0428271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01860773Medicaid