Provider Demographics
NPI:1639619208
Name:CLOVE LAKES FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:CLOVE LAKES FAMILY DENTAL PLLC
Other - Org Name:OAKWOOD DENTAL ARTS OF CLOVE LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:EMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAZIANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-873-4889
Mailing Address - Street 1:1140 VICTORY BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3673
Mailing Address - Country:US
Mailing Address - Phone:718-255-8995
Mailing Address - Fax:
Practice Address - Street 1:1140 VICTORY BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3673
Practice Address - Country:US
Practice Address - Phone:718-255-8995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental