Provider Demographics
NPI:1699922088
Name:HOLLIS ADVANCED DENTAL CARE P.C.
Entity type:Organization
Organization Name:HOLLIS ADVANCED DENTAL CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:V
Authorized Official - Last Name:KATAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-454-7418
Mailing Address - Street 1:19002 JAMAICA AVE
Mailing Address - Street 2:2 FLOOR
Mailing Address - City:HOLLIS
Mailing Address - State:NY
Mailing Address - Zip Code:11423-2516
Mailing Address - Country:US
Mailing Address - Phone:718-454-7418
Mailing Address - Fax:718-217-2657
Practice Address - Street 1:19002 JAMAICA AVE
Practice Address - Street 2:2 FLOOR
Practice Address - City:HOLLIS
Practice Address - State:NY
Practice Address - Zip Code:11423-2516
Practice Address - Country:US
Practice Address - Phone:718-454-7418
Practice Address - Fax:718-217-2657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122300000X, 1223P0300X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011896900Medicaid
NY02587795Medicaid