Provider Demographics
NPI:1801156674
Name:OAKDALE MALL DENTAL LLP
Entity type:Organization
Organization Name:OAKDALE MALL DENTAL LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:607-770-8888
Mailing Address - Street 1:601-635 HARRY L DR
Mailing Address - Street 2:46
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-1246
Mailing Address - Country:US
Mailing Address - Phone:607-770-8888
Mailing Address - Fax:607-770-8881
Practice Address - Street 1:601-635 HARRY L DR
Practice Address - Street 2:46
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-1246
Practice Address - Country:US
Practice Address - Phone:607-770-8888
Practice Address - Fax:607-770-8881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-25
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01580001Medicaid