Provider Demographics
NPI:1952544033
Name:TRUSTEES OF COLUMBIA UNIVERSITY
Entity Type:Organization
Organization Name:TRUSTEES OF COLUMBIA UNIVERSITY
Other - Org Name:HARLEM FACULTY PRACTICE - ORAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUDHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENTYALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-579-6021
Mailing Address - Street 1:506 LENOX AVENUE
Mailing Address - Street 2:WP BUILDING, 7TH FLOOR, ROOM 742
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1889
Mailing Address - Country:US
Mailing Address - Phone:212-939-3501
Mailing Address - Fax:
Practice Address - Street 1:506 LENOX AVE
Practice Address - Street 2:WP BUILDING, 7TH FLOOR, ROOM 742
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-3501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02866071Medicaid