Provider Demographics
NPI:1922433390
Name:FLUSHING DENTAL PC
Entity Type:Organization
Organization Name:FLUSHING DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:YI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-460-9440
Mailing Address - Street 1:3535 149TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-3785
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 149TH ST STE 203
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-3785
Practice Address - Country:US
Practice Address - Phone:718-460-9440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-04
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0510471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02495687Medicaid