Provider Demographics
NPI:1699076083
Name:URBAN PEDIATRIC DENTAL PC
Entity type:Organization
Organization Name:URBAN PEDIATRIC DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LOO
Authorized Official - Last Name:MARN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-965-8113
Mailing Address - Street 1:128 MOTT STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-5575
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 MOTT STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-5575
Practice Address - Country:US
Practice Address - Phone:212-965-8113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-16
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0497501302F00000X
NY0535941302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02902734Medicaid