Provider Demographics
NPI:1568851954
Name:BORO PARK DENTAL ASSOC.
Entity type:Organization
Organization Name:BORO PARK DENTAL ASSOC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-871-6663
Mailing Address - Street 1:1520 50TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-3745
Mailing Address - Country:US
Mailing Address - Phone:718-871-6663
Mailing Address - Fax:718-431-2452
Practice Address - Street 1:1520 50TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-3745
Practice Address - Country:US
Practice Address - Phone:718-871-6663
Practice Address - Fax:718-431-2452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00301428Medicaid
NY03534690Medicaid
NY03448359Medicaid