Provider Demographics
NPI:1841389046
Name:CORONA FAMILY DENTAL ASSOC PC
Entity Type:Organization
Organization Name:CORONA FAMILY DENTAL ASSOC PC
Other - Org Name:CORONA FAMILY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-645-3000
Mailing Address - Street 1:1956 OCEAN PARKWAY
Mailing Address - Street 2:1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223
Mailing Address - Country:US
Mailing Address - Phone:718-645-3000
Mailing Address - Fax:718-645-4393
Practice Address - Street 1:3766 JUNCTION BOULEVARD
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368
Practice Address - Country:US
Practice Address - Phone:718-898-1300
Practice Address - Fax:718-533-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02419670Medicaid