Provider Demographics
NPI:1649318601
Name:SAND LANE DENTAL PC
Entity type:Organization
Organization Name:SAND LANE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDZHELA
Authorized Official - Middle Name:P
Authorized Official - Last Name:TKACHUK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-273-5006
Mailing Address - Street 1:67 CLAWSON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3222
Mailing Address - Country:US
Mailing Address - Phone:718-273-5006
Mailing Address - Fax:718-273-2778
Practice Address - Street 1:128 SAND LN
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-4543
Practice Address - Country:US
Practice Address - Phone:718-273-5006
Practice Address - Fax:718-273-2778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0506791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02408771Medicaid
NY02410680Medicaid
NYA00027936Medicare PIN
NY02410680Medicaid
NY02408771Medicaid