Provider Demographics
NPI:1609210178
Name:CORRECTIONAL DENTAL ASSOCIATES OF NEW YORK
Entity Type:Organization
Organization Name:CORRECTIONAL DENTAL ASSOCIATES OF NEW YORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:AMBROSE
Authorized Official - Last Name:HAYLING
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-774-7800
Mailing Address - Street 1:4904 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1002
Mailing Address - Country:US
Mailing Address - Phone:347-774-7800
Mailing Address - Fax:718-777-7820
Practice Address - Street 1:4904 19TH AVE
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1002
Practice Address - Country:US
Practice Address - Phone:347-774-7800
Practice Address - Fax:718-777-7820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-26
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051827-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty