Provider Demographics
NPI:1063779478
Name:ILLUSTRADENT WESTCHESTER DENTAL SERVICES, PLLC
Entity type:Organization
Organization Name:ILLUSTRADENT WESTCHESTER DENTAL SERVICES, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:914-779-4858
Mailing Address - Street 1:1730 CENTRAL PARK AVE
Mailing Address - Street 2:SUITE 2R
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-4905
Mailing Address - Country:US
Mailing Address - Phone:914-779-4858
Mailing Address - Fax:914-395-0101
Practice Address - Street 1:1730 CENTRAL PARK AVE
Practice Address - Street 2:SUITE 2R
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-4905
Practice Address - Country:US
Practice Address - Phone:914-779-4858
Practice Address - Fax:914-395-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0528581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty