Provider Demographics
NPI:1851781561
Name:ELIZABETH AVENUE DENTISTRY, PC
Entity Type:Organization
Organization Name:ELIZABETH AVENUE DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAYLOMSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:917-658-7537
Mailing Address - Street 1:643 ELIZABETH AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07206-1131
Mailing Address - Country:US
Mailing Address - Phone:908-354-0030
Mailing Address - Fax:908-354-4029
Practice Address - Street 1:643 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07206-1131
Practice Address - Country:US
Practice Address - Phone:908-354-0030
Practice Address - Fax:908-354-4029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22424261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental