Provider Demographics
NPI:1306931514
Name:MILLENNIUM SMILE DENTISTRY, PC
Entity type:Organization
Organization Name:MILLENNIUM SMILE DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VITALIY
Authorized Official - Middle Name:
Authorized Official - Last Name:FABRIKANT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:212-740-7568
Mailing Address - Street 1:120 CABRINI BLVD
Mailing Address - Street 2:#10
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-3438
Mailing Address - Country:US
Mailing Address - Phone:212-740-7568
Mailing Address - Fax:212-740-7568
Practice Address - Street 1:120 CABRINI BLVD
Practice Address - Street 2:#10
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-3438
Practice Address - Country:US
Practice Address - Phone:212-740-7568
Practice Address - Fax:212-740-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048425261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02525684Medicaid
NY=========OtherALL INSURANCES