Provider Demographics
NPI:1922454909
Name:BROOKLYN DENTAL PROFESSIONALS
Entity Type:Organization
Organization Name:BROOKLYN DENTAL PROFESSIONALS
Other - Org Name:BROOKLYN DENTAL PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:KOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-486-7600
Mailing Address - Street 1:700 GRAND STREET
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11211-4939
Mailing Address - Country:US
Mailing Address - Phone:718-486-7600
Mailing Address - Fax:
Practice Address - Street 1:700 GRAND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211-4939
Practice Address - Country:US
Practice Address - Phone:718-486-7600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051647122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty