Provider Demographics
NPI:1609247014
Name:HOUSE OF BRACES QUEENS ORTHODONTIC PC
Entity Type:Organization
Organization Name:HOUSE OF BRACES QUEENS ORTHODONTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-267-1800
Mailing Address - Street 1:4235 MAIN ST STE 3F
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3956
Mailing Address - Country:US
Mailing Address - Phone:718-888-7781
Mailing Address - Fax:
Practice Address - Street 1:4235 MAIN ST STE 3F
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3956
Practice Address - Country:US
Practice Address - Phone:718-888-7781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY423241223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty