Provider Demographics
NPI:1932326618
Name:GALLERIA MALL DENTAL PC
Entity Type:Organization
Organization Name:GALLERIA MALL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-692-9212
Mailing Address - Street 1:1 N GALLERIA DR STE 141
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-3030
Mailing Address - Country:US
Mailing Address - Phone:845-692-9212
Mailing Address - Fax:845-692-9215
Practice Address - Street 1:1 N GALLERIA DR STE 141
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-3030
Practice Address - Country:US
Practice Address - Phone:845-692-9212
Practice Address - Fax:845-692-9215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049213122300000X
NY052828122300000X
NY0487601223P0221X
NY0427071223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty