Provider Demographics
NPI:1104352012
Name:OCEAN-SIDE DENTAL P.C.
Entity type:Organization
Organization Name:OCEAN-SIDE DENTAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRISIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONCHARUK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-908-0464
Mailing Address - Street 1:3260 CONEY ISLAND AVE
Mailing Address - Street 2:UNIT A4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6643
Mailing Address - Country:US
Mailing Address - Phone:718-891-0021
Mailing Address - Fax:718-891-4946
Practice Address - Street 1:3260 CONEY ISLAND AVE
Practice Address - Street 2:UNIT A4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6643
Practice Address - Country:US
Practice Address - Phone:718-891-0021
Practice Address - Fax:718-891-4946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049909-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty