Provider Demographics
NPI:1306915822
Name:PROFESSIONAL DENTAL ASSOCIATES PC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BERNARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:RUPNARAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MSD
Authorized Official - Phone:718-728-8844
Mailing Address - Street 1:3119 NEWTOWN AVE
Mailing Address - Street 2:SUITE 800
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-1350
Mailing Address - Country:US
Mailing Address - Phone:718-728-8844
Mailing Address - Fax:718-728-6795
Practice Address - Street 1:3119 NEWTOWN AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-1350
Practice Address - Country:US
Practice Address - Phone:718-728-8844
Practice Address - Fax:718-728-6795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0436221223G0001X
NY0463681223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty