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125TH STREET DENTAL LLP

General Practice Dentist

New York, New York

Provider NPI: 1861523771

Organization Information:
Organization Name:  125TH STREET DENTAL LLP
Authorized Official:  SERGUEI  KOPETSKOV  PRESIDENT  646-8279819

Practice Location:
437 W 125TH ST  NEW YORK, NY 10027 US
Tel: 646-827-9819  Fax: 646-827-0510

Business Mailing Address:
437 W 125TH ST  NEW YORK, NY 10027 US
Tel: 646-827-9819  Fax: 646-827-0510

Entity Type: Organization

Taxonomy:

PrimaryCodeCategory/DescriptionStateLicense Number
Y1223G0001XDental Providers
Dentist
General Practice
NY049097

Other Provider Identifiers:

IssuerNumberStateType
02772787NY05
Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin



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