Provider Demographics
NPI:1972931541
Name:BROOKLYN ORTHODONTICS
Entity type:Organization
Organization Name:BROOKLYN ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:AL-JANABI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-333-5898
Mailing Address - Street 1:9012 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-5908
Mailing Address - Country:US
Mailing Address - Phone:718-333-5898
Mailing Address - Fax:
Practice Address - Street 1:9012 5TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-5908
Practice Address - Country:US
Practice Address - Phone:718-333-5898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0566481223S0112X
NY2715331223S0112X
NY0531521223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03169913Medicaid