Provider Demographics
NPI:1609048461
Name:MODERN DENTAL CONCEPTS OF NY, PC
Entity Type:Organization
Organization Name:MODERN DENTAL CONCEPTS OF NY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:REZNIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-343-2772
Mailing Address - Street 1:1595 STRAIGHT PATH
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-2407
Mailing Address - Country:US
Mailing Address - Phone:516-343-2772
Mailing Address - Fax:
Practice Address - Street 1:1595 STRAIGHT PATH
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-2407
Practice Address - Country:US
Practice Address - Phone:516-343-2772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049260-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02156141Medicaid