Provider Demographics
NPI:1134628415
Name:57 CENTRAL DENTAL PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:57 CENTRAL DENTAL PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUNG-HUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-442-9164
Mailing Address - Street 1:100 OLD PALISADE RD APT 2705
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-7022
Mailing Address - Country:US
Mailing Address - Phone:917-442-9164
Mailing Address - Fax:
Practice Address - Street 1:57 W 57TH ST STE 710
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2802
Practice Address - Country:US
Practice Address - Phone:212-564-1888
Practice Address - Fax:212-564-1161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0515321223G0001X
NY0512751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty