Provider Demographics
NPI:1942819834
Name:INTEGRATIVE MIND BODY DENTAL TELEHEALTH LLC
Entity Type:Organization
Organization Name:INTEGRATIVE MIND BODY DENTAL TELEHEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:EDALAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-371-0360
Mailing Address - Street 1:30 CENTRAL PARK S RM 4C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1628
Mailing Address - Country:US
Mailing Address - Phone:212-371-0360
Mailing Address - Fax:
Practice Address - Street 1:30 CENTRAL PARK S RM 4C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1628
Practice Address - Country:US
Practice Address - Phone:212-371-0360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty