Provider Demographics
NPI:1255724878
Name:NSLIJ DENTAL MEDICINE
Entity type:Organization
Organization Name:NSLIJ DENTAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL GENERAL PRACTICE RESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KRIVCA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-209-4779
Mailing Address - Street 1:400 COMMUNITY DR
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3815
Mailing Address - Country:US
Mailing Address - Phone:347-209-4779
Mailing Address - Fax:
Practice Address - Street 1:400 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3815
Practice Address - Country:US
Practice Address - Phone:347-209-4779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2015-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental