Provider Demographics
NPI:1285079962
Name:BOUTIQUE DENTAL
Entity type:Organization
Organization Name:BOUTIQUE DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MULLAKANDOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-640-1100
Mailing Address - Street 1:6835 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7234
Mailing Address - Country:US
Mailing Address - Phone:718-821-0170
Mailing Address - Fax:
Practice Address - Street 1:6835 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7234
Practice Address - Country:US
Practice Address - Phone:718-821-0170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-07
Last Update Date:2014-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055256261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03263605Medicaid