Provider Demographics
NPI:1790088730
Name:BLUE BAY DENTAL, PC
Entity Type:Organization
Organization Name:BLUE BAY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WENXIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZHOU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PHD
Authorized Official - Phone:718-888-9118
Mailing Address - Street 1:13620 38TH AVE STE 8D
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4232
Mailing Address - Country:US
Mailing Address - Phone:718-888-9118
Mailing Address - Fax:718-888-0508
Practice Address - Street 1:13620 38TH AVE STE 8D
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4232
Practice Address - Country:US
Practice Address - Phone:718-888-9118
Practice Address - Fax:718-888-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0550801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03242697Medicaid