Provider Demographics
NPI:1710218953
Name:WESTSIDE FAMILY DENTAL GROUP
Entity Type:Organization
Organization Name:WESTSIDE FAMILY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARKEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-496-9600
Mailing Address - Street 1:400 W END AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10024-5751
Mailing Address - Country:US
Mailing Address - Phone:212-496-9600
Mailing Address - Fax:
Practice Address - Street 1:400 W END AVE APT 1B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-5751
Practice Address - Country:US
Practice Address - Phone:212-496-9600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035345122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty