Provider Demographics
NPI:1790981579
Name:EVERGREEN DENTISTRY, LLC
Entity Type:Organization
Organization Name:EVERGREEN DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-578-1126
Mailing Address - Street 1:4748 203RD ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3039
Mailing Address - Country:US
Mailing Address - Phone:718-578-1126
Mailing Address - Fax:718-578-1126
Practice Address - Street 1:4748 203RD ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3039
Practice Address - Country:US
Practice Address - Phone:718-578-1126
Practice Address - Fax:718-578-1126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050969261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02685578Medicaid