Provider Demographics
NPI:1205086147
Name:82ND DENTAL PLLC
Entity type:Organization
Organization Name:82ND DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:FARAMARZ
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALILI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-476-5555
Mailing Address - Street 1:8201 ROOSEVELT AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7034
Mailing Address - Country:US
Mailing Address - Phone:718-476-5555
Mailing Address - Fax:718-476-6666
Practice Address - Street 1:8201 ROOSEVELT AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7034
Practice Address - Country:US
Practice Address - Phone:718-476-5555
Practice Address - Fax:718-476-6666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01804719Medicaid