Provider Demographics
NPI:1588749881
Name:CONCOURSE WEST MANAGEMENT INC
Entity type:Organization
Organization Name:CONCOURSE WEST MANAGEMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KUPPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-992-0410
Mailing Address - Street 1:880 RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-9431
Mailing Address - Country:US
Mailing Address - Phone:718-992-0410
Mailing Address - Fax:718-538-4323
Practice Address - Street 1:880 RIVER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-9431
Practice Address - Country:US
Practice Address - Phone:718-992-0410
Practice Address - Fax:718-538-4323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0504041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01762532Medicaid