Provider Demographics
NPI:1770797771
Name:PARK AVENUE DENTAL GROUP
Entity type:Organization
Organization Name:PARK AVENUE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:APTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHODS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-951-7104
Mailing Address - Street 1:37 PARK AVENUE
Mailing Address - Street 2:(SUITE A)
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016
Mailing Address - Country:US
Mailing Address - Phone:212-951-7104
Mailing Address - Fax:212-951-7105
Practice Address - Street 1:37 PARK AVENUE
Practice Address - Street 2:(SUITE A)
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:212-951-7104
Practice Address - Fax:212-951-7105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0452461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01521833Medicaid