Provider Demographics
NPI:1790219467
Name:PEDIATRIC DENTISTRY OF NANUET PLLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF NANUET PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYER
Authorized Official - Middle Name:
Authorized Official - Last Name:NOSKOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:845-507-0100
Mailing Address - Street 1:55 OLD NYACK TPKE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2461
Mailing Address - Country:US
Mailing Address - Phone:845-507-0100
Mailing Address - Fax:845-507-0110
Practice Address - Street 1:55 OLD NYACK TPKE
Practice Address - Street 2:SUITE 109
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2461
Practice Address - Country:US
Practice Address - Phone:845-507-0100
Practice Address - Fax:845-507-0110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0556231223P0221X
NY0557731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty