Provider Demographics
NPI:1609913805
Name:AUDUBON DENTAL PC
Entity Type:Organization
Organization Name:AUDUBON DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:FIOR
Authorized Official - Middle Name:BENEY
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-795-3486
Mailing Address - Street 1:550 W 180TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-5806
Mailing Address - Country:US
Mailing Address - Phone:212-795-3486
Mailing Address - Fax:212-543-3230
Practice Address - Street 1:550 W 180TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-5806
Practice Address - Country:US
Practice Address - Phone:212-795-3486
Practice Address - Fax:212-543-3230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01923922Medicaid