Provider Demographics
NPI:1295892735
Name:DEMO DENTAL, P.C.
Entity type:Organization
Organization Name:DEMO DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ZILBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-443-5500
Mailing Address - Street 1:792 FLUSHING AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-4106
Mailing Address - Country:US
Mailing Address - Phone:718-443-5500
Mailing Address - Fax:718-443-5501
Practice Address - Street 1:792 FLUSHING AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-4106
Practice Address - Country:US
Practice Address - Phone:718-443-5500
Practice Address - Fax:718-443-5501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046369261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01662679Medicaid