Provider Demographics
NPI:1912415597
Name:LAKEWOOD KIDS AND ADOLESCENT DENTISTRY
Entity Type:Organization
Organization Name:LAKEWOOD KIDS AND ADOLESCENT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NASSI
Authorized Official - Middle Name:
Authorized Official - Last Name:FIGDOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-613-1934
Mailing Address - Street 1:5510 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-1814
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1776 AVENUE OF THE STATES
Practice Address - Street 2:SUITE 105
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701
Practice Address - Country:US
Practice Address - Phone:917-613-1934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental