Provider Demographics
NPI:1902186695
Name:77 DENTAL PC
Entity Type:Organization
Organization Name:77 DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MANOHAR
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHRESTHA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-779-3324
Mailing Address - Street 1:37-40 77 STREET
Mailing Address - Street 2:1ST FL
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-6630
Mailing Address - Country:US
Mailing Address - Phone:718-779-3324
Mailing Address - Fax:718-779-3324
Practice Address - Street 1:37-40 77 STREET
Practice Address - Street 2:1ST FL
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-6630
Practice Address - Country:US
Practice Address - Phone:718-779-3324
Practice Address - Fax:718-779-3324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental