Provider Demographics
NPI:1720357726
Name:21ST CENTURYDENTAL COSMETIC HEALTH P.C
Entity Type:Organization
Organization Name:21ST CENTURYDENTAL COSMETIC HEALTH P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAHRYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SEDGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-384-2662
Mailing Address - Street 1:738 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-4403
Mailing Address - Country:US
Mailing Address - Phone:718-384-2662
Mailing Address - Fax:718-384-6408
Practice Address - Street 1:738 BROADWAY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4403
Practice Address - Country:US
Practice Address - Phone:718-384-2662
Practice Address - Fax:718-384-6408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0471411223G0001X
NY0430661223G0001X
NY0469851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1508919820Medicaid
NY1346470192Medicaid
NY1851506596Medicaid