Provider Demographics
NPI:1154533156
Name:PARKCHESTER CHILDRENS DENTAL GROUP
Entity type:Organization
Organization Name:PARKCHESTER CHILDRENS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-824-9612
Mailing Address - Street 1:1488 METROPOLITAN AVENUE
Mailing Address - Street 2:STE 7
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462
Mailing Address - Country:US
Mailing Address - Phone:718-824-9612
Mailing Address - Fax:718-824-9614
Practice Address - Street 1:1488 METROPOLITAN AVENUE
Practice Address - Street 2:STE 7
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462
Practice Address - Country:US
Practice Address - Phone:718-824-9612
Practice Address - Fax:718-824-9614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0471691122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01788352Medicaid