Provider Demographics
NPI:1104112267
Name:DYNAMIC DENTAL SERVICES
Entity type:Organization
Organization Name:DYNAMIC DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-274-6741
Mailing Address - Street 1:2121 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180-2849
Mailing Address - Country:US
Mailing Address - Phone:518-274-6741
Mailing Address - Fax:518-274-6748
Practice Address - Street 1:2121 6TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2849
Practice Address - Country:US
Practice Address - Phone:518-274-6741
Practice Address - Fax:518-274-6748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04449-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01568836Medicaid