Provider Demographics
NPI:1619213436
Name:MDA DENTAL GROUP
Entity Type:Organization
Organization Name:MDA DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC MORDECAI
Authorized Official - Middle Name:
Authorized Official - Last Name:LIECHTUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-247-2330
Mailing Address - Street 1:1995 BROADWAY STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-5882
Mailing Address - Country:US
Mailing Address - Phone:212-247-2330
Mailing Address - Fax:
Practice Address - Street 1:1995 BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-5882
Practice Address - Country:US
Practice Address - Phone:212-247-2330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040754-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty