Provider Demographics
NPI:1245695030
Name:WYCKOFF HEIGHTS DENTAL SERVICES, PC
Entity type:Organization
Organization Name:WYCKOFF HEIGHTS DENTAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:VUTRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-963-6702
Mailing Address - Street 1:374 STOCKHOLM STREET
Mailing Address - Street 2:WYCKOFF HEIGHTS MEDICAL CENTER - FACULTY PRACTICE
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11237
Mailing Address - Country:US
Mailing Address - Phone:718-963-7272
Mailing Address - Fax:
Practice Address - Street 1:WYCKOFF PEDIATRIC CARE CENTER - 1411 MYRTLE AVENUE
Practice Address - Street 2:WYCKOFF HEIGHTS DENTAL SERVICES, PC
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237
Practice Address - Country:US
Practice Address - Phone:718-907-4301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WYCKOFF HEIGHTS DENTAL SERVICES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01894164Medicaid
NYA100111469Medicare PIN