Provider Demographics
NPI:1760452106
Name:JACKSON HEIGHTS DENTAL MR, PC
Entity Type:Organization
Organization Name:JACKSON HEIGHTS DENTAL MR, PC
Other - Org Name:JACKSON HEIGHTS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:LORBER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-651-4523
Mailing Address - Street 1:8509 37TH AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7344
Mailing Address - Country:US
Mailing Address - Phone:718-651-4523
Mailing Address - Fax:
Practice Address - Street 1:8509 37TH AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7344
Practice Address - Country:US
Practice Address - Phone:718-651-4523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047347122300000X
NY046409122300000X
NY0520711223G0001X
NY0473031223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01912481Medicaid