Provider Demographics
NPI:1790957637
Name:MA DENTAL PC
Entity Type:Organization
Organization Name:MA DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:DEL SOCORRO
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-781-4373
Mailing Address - Street 1:295 FORT WASHINGTON AVE APT C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1210
Mailing Address - Country:US
Mailing Address - Phone:212-781-4674
Mailing Address - Fax:212-781-4675
Practice Address - Street 1:295 FORT WASHINGTON AVE APT C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1210
Practice Address - Country:US
Practice Address - Phone:212-781-4674
Practice Address - Fax:212-781-4675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048018261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental