Provider Demographics
NPI:1669764015
Name:PRIMARY CARE DENTAL PC
Entity type:Organization
Organization Name:PRIMARY CARE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:914-946-9098
Mailing Address - Street 1:99 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HARTSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10530-1564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 FIELDSTONE DR
Practice Address - Street 2:
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-1564
Practice Address - Country:US
Practice Address - Phone:914-997-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-04
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044694-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty