Provider Demographics
NPI:1720156870
Name:BLUESTAR DENTAL CARE
Entity Type:Organization
Organization Name:BLUESTAR DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF DENTAL AND ORAL MED
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-209-8500
Mailing Address - Street 1:2110 ROCKAWAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5802
Mailing Address - Country:US
Mailing Address - Phone:718-209-8500
Mailing Address - Fax:718-942-4582
Practice Address - Street 1:2110 ROCKAWAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-5802
Practice Address - Country:US
Practice Address - Phone:718-209-8500
Practice Address - Fax:718-942-4582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049832-1122300000X
NY049803-1122300000X
NY047926-11223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02769157Medicaid