Provider Demographics
NPI:1952573594
Name:BOYNTON DENTAL,PC
Entity Type:Organization
Organization Name:BOYNTON DENTAL,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:FATOUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-617-0624
Mailing Address - Street 1:1537 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10472-2908
Mailing Address - Country:US
Mailing Address - Phone:718-617-0624
Mailing Address - Fax:718-328-3887
Practice Address - Street 1:1537 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10472-2908
Practice Address - Country:US
Practice Address - Phone:718-617-0624
Practice Address - Fax:718-328-3887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0419731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01087961Medicaid
NY01115177Medicaid