Provider Demographics
NPI:1851946271
Name:GREENBURGH KIDS DENTAL, PC
Entity Type:Organization
Organization Name:GREENBURGH KIDS DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-405-2001
Mailing Address - Street 1:99 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-1564
Mailing Address - Country:US
Mailing Address - Phone:914-997-8820
Mailing Address - Fax:
Practice Address - Street 1:99 FIELDSTONE DR
Practice Address - Street 2:
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-1564
Practice Address - Country:US
Practice Address - Phone:914-997-8820
Practice Address - Fax:914-997-9627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-02
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03260895Medicaid