Provider Demographics
NPI:1609278233
Name:WOODHAVEN DENTAL GROUP, PLLC
Entity Type:Organization
Organization Name:WOODHAVEN DENTAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUNCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-850-5555
Mailing Address - Street 1:8708 WOODHAVEN BLVD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:WOODHAVEN
Mailing Address - State:NY
Mailing Address - Zip Code:11421-2284
Mailing Address - Country:US
Mailing Address - Phone:718-850-5555
Mailing Address - Fax:718-805-9000
Practice Address - Street 1:8708 WOODHAVEN BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WOODHAVEN
Practice Address - State:NY
Practice Address - Zip Code:11421-2284
Practice Address - Country:US
Practice Address - Phone:718-850-5555
Practice Address - Fax:718-805-9000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-26
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0510191223P0221X, 124Q00000X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty