Provider Demographics
NPI:1659628402
Name:MIDTOWN DENTAL, PC
Entity Type:Organization
Organization Name:MIDTOWN DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMUELOVA-TETRI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-748-1742
Mailing Address - Street 1:57 W 57TH ST
Mailing Address - Street 2:SUITE #700
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2802
Mailing Address - Country:US
Mailing Address - Phone:917-748-1742
Mailing Address - Fax:
Practice Address - Street 1:57 W 57TH ST
Practice Address - Street 2:SUITE #700
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2802
Practice Address - Country:US
Practice Address - Phone:917-748-1742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-11
Last Update Date:2012-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0517381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty