Provider Demographics
NPI:1750434809
Name:SPECIALTY DENTAL OF GREENPOINT, P.C.
Entity type:Organization
Organization Name:SPECIALTY DENTAL OF GREENPOINT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:J
Authorized Official - Last Name:PTAK
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-383-0933
Mailing Address - Street 1:92 NORMAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11222-2934
Mailing Address - Country:US
Mailing Address - Phone:718-383-0933
Mailing Address - Fax:718-349-0930
Practice Address - Street 1:92 NORMAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-2934
Practice Address - Country:US
Practice Address - Phone:718-383-0933
Practice Address - Fax:718-349-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05223911223P0221X
NY0347441223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00782729Medicaid
NY00782729Medicaid
NYT49500Medicare UPIN