Provider Demographics
NPI:1205970332
Name:DISTINCTIVE DENTAL SERVICES OF NEW YORK PC
Entity type:Organization
Organization Name:DISTINCTIVE DENTAL SERVICES OF NEW YORK PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:EPSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-487-8110
Mailing Address - Street 1:173 EAST SHORE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023
Mailing Address - Country:US
Mailing Address - Phone:516-487-8110
Mailing Address - Fax:516-487-8394
Practice Address - Street 1:173 E SHORE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-2415
Practice Address - Country:US
Practice Address - Phone:516-487-8110
Practice Address - Fax:516-487-8394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X, 1223P0221X
NY342271223D0004X
NY054882122300000X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty