Provider Demographics
NPI:1356580914
Name:4TH AVENUE DENTAL PC
Entity type:Organization
Organization Name:4TH AVENUE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HARESH
Authorized Official - Middle Name:I
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:914-664-5342
Mailing Address - Street 1:11033 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1428
Mailing Address - Country:US
Mailing Address - Phone:917-886-4568
Mailing Address - Fax:718-275-3049
Practice Address - Street 1:157 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-3106
Practice Address - Country:US
Practice Address - Phone:914-664-5342
Practice Address - Fax:718-275-3049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0366301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00729819Medicaid