Provider Demographics
NPI:1336991876
Name:BLACK HALL DENTAL, P.C.
Entity Type:Organization
Organization Name:BLACK HALL DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-441-5131
Mailing Address - Street 1:1999 MARCUS AVE STE M1
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1023
Mailing Address - Country:US
Mailing Address - Phone:516-441-5131
Mailing Address - Fax:
Practice Address - Street 1:1999 MARCUS AVE STE M1
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1023
Practice Address - Country:US
Practice Address - Phone:516-441-5131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLACK HALL DENTAL, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty