Provider Demographics
NPI:1881991214
Name:DEBORAHNINADENTALOFFICEPC
Entity type:Organization
Organization Name:DEBORAHNINADENTALOFFICEPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NINA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-429-6622
Mailing Address - Street 1:9203 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7941
Mailing Address - Country:US
Mailing Address - Phone:718-429-6622
Mailing Address - Fax:718-429-6669
Practice Address - Street 1:9203 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7941
Practice Address - Country:US
Practice Address - Phone:718-429-6622
Practice Address - Fax:718-429-6669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-21
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055474-1122300000X
NY048101-1122300000X
NY048800-11223G0001X
NY052578-11223G0001X
NY055242-11223G0001X
NY050127-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02348667Medicaid