Provider Demographics
NPI:1831444355
Name:SOUTH BRONX ORTHODONTICS
Entity type:Organization
Organization Name:SOUTH BRONX ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-373-6707
Mailing Address - Street 1:2825 3RD AVE
Mailing Address - Street 2:SUITE 406 (4TH FLOOR)
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10455-4003
Mailing Address - Country:US
Mailing Address - Phone:718-292-4700
Mailing Address - Fax:
Practice Address - Street 1:2825 3RD AVE
Practice Address - Street 2:SUITE 406 (4TH FLOOR)
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4003
Practice Address - Country:US
Practice Address - Phone:718-292-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047218-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty