Provider Demographics
NPI:1013499052
Name:12TH STREET DENTAL PLLC
Entity Type:Organization
Organization Name:12TH STREET DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:JANASH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:917-915-4504
Mailing Address - Street 1:30 CENTRAL PARK S RM 13C
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1646
Mailing Address - Country:US
Mailing Address - Phone:212-355-2000
Mailing Address - Fax:
Practice Address - Street 1:77 E 12TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-5002
Practice Address - Country:US
Practice Address - Phone:917-915-4504
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0516101223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Multi-Specialty