Provider Demographics
NPI:1760862775
Name:PARKSIDE DENTAL PC
Entity Type:Organization
Organization Name:PARKSIDE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSKALENCO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-462-7436
Mailing Address - Street 1:325 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5560
Mailing Address - Country:US
Mailing Address - Phone:718-462-7436
Mailing Address - Fax:718-462-2418
Practice Address - Street 1:325 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-5560
Practice Address - Country:US
Practice Address - Phone:718-462-7436
Practice Address - Fax:718-462-2418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0530351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02858868Medicaid