Provider Demographics
NPI:1760654974
Name:PROFESSIONAL DENTAL SERVICE
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MARIA-DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-738-0005
Mailing Address - Street 1:611 W 156TH ST
Mailing Address - Street 2:SUITE 55
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-7508
Mailing Address - Country:US
Mailing Address - Phone:212-738-0005
Mailing Address - Fax:212-368-4391
Practice Address - Street 1:611 W 156TH ST
Practice Address - Street 2:SUITE 55
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-7508
Practice Address - Country:US
Practice Address - Phone:212-738-0005
Practice Address - Fax:212-368-4391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052157-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02694315Medicaid
NY9200203OtherDORAL