Provider Demographics
NPI:1881993392
Name:FOURTH AVENUE DENTAL
Entity type:Organization
Organization Name:FOURTH AVENUE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MARON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-439-2876
Mailing Address - Street 1:5404 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-3006
Mailing Address - Country:US
Mailing Address - Phone:718-439-2876
Mailing Address - Fax:718-439-2879
Practice Address - Street 1:5404 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3006
Practice Address - Country:US
Practice Address - Phone:718-439-2876
Practice Address - Fax:718-439-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-23
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03170656Medicaid