Provider Demographics
NPI:1639370380
Name:HUSSEIN Y ABDELWAHAB, DDS, PC
Entity Type:Organization
Organization Name:HUSSEIN Y ABDELWAHAB, DDS, PC
Other - Org Name:BRILLIANCE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-951-5105
Mailing Address - Street 1:3105 CHURCH AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-4211
Mailing Address - Country:US
Mailing Address - Phone:718-287-1300
Mailing Address - Fax:718-287-5530
Practice Address - Street 1:3105 CHURCH AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-4211
Practice Address - Country:US
Practice Address - Phone:718-287-1300
Practice Address - Fax:718-287-5530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0464461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01739179Medicaid