Provider Demographics
NPI:1679781611
Name:MOTT STREET DENTAL P.C
Entity Type:Organization
Organization Name:MOTT STREET DENTAL P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IVY
Authorized Official - Middle Name:X
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-732-5875
Mailing Address - Street 1:2 MOTT ST RM 303
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-5003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 MOTT ST RM 303
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-5003
Practice Address - Country:US
Practice Address - Phone:212-732-5875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049014122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02758381Medicaid