Provider Demographics
NPI:1639417801
Name:MANHATTAN DENTISTRY COSMETY
Entity Type:Organization
Organization Name:MANHATTAN DENTISTRY COSMETY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:IBELKA
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-568-1003
Mailing Address - Street 1:461 FORT WASHINGTON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-4632
Mailing Address - Country:US
Mailing Address - Phone:212-568-1003
Mailing Address - Fax:212-568-5715
Practice Address - Street 1:461 FORT WASHINGTON AVE APT 1
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-4632
Practice Address - Country:US
Practice Address - Phone:212-568-1003
Practice Address - Fax:212-568-5715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050317-11223G0001X
NY0525431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2711071Medicaid
NY2329808Medicaid