Provider Demographics
NPI:1588998405
Name:NEW YORK AVENUE DENTAL
Entity type:Organization
Organization Name:NEW YORK AVENUE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FADI
Authorized Official - Middle Name:I
Authorized Official - Last Name:BEYDOUN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:201-305-8800
Mailing Address - Street 1:3703 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07087-4807
Mailing Address - Country:US
Mailing Address - Phone:201-305-8800
Mailing Address - Fax:201-305-8900
Practice Address - Street 1:3703 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-4807
Practice Address - Country:US
Practice Address - Phone:201-305-8800
Practice Address - Fax:201-305-8900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ19152261QD0000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0208540Medicaid