Provider Demographics
NPI:1124289533
Name:SAM'S FAMILY DENTAL
Entity type:Organization
Organization Name:SAM'S FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDEEP
Authorized Official - Middle Name:
Authorized Official - Last Name:BHAGAT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-429-5256
Mailing Address - Street 1:39-79 61ST STREET ROOSEVELT AVENUE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377
Mailing Address - Country:US
Mailing Address - Phone:718-429-5256
Mailing Address - Fax:
Practice Address - Street 1:39-79 61 STREET ROOSEVELT AVENUE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377
Practice Address - Country:US
Practice Address - Phone:718-429-5256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0487671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02074784Medicaid