Provider Demographics
NPI:1760520852
Name:AVENUE D PROFESSIONAL GROUP P.C.
Entity Type:Organization
Organization Name:AVENUE D PROFESSIONAL GROUP P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-451-1888
Mailing Address - Street 1:4401 AVENUE D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5725
Mailing Address - Country:US
Mailing Address - Phone:718-451-1888
Mailing Address - Fax:718-451-1920
Practice Address - Street 1:4401 AVENUE D
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5725
Practice Address - Country:US
Practice Address - Phone:718-451-1888
Practice Address - Fax:718-451-1920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0352211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty