Provider Demographics
NPI:1992127765
Name:125TH STREET ORTHODONTICS, PC
Entity type:Organization
Organization Name:125TH STREET ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:COOPERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:646-221-8944
Mailing Address - Street 1:789 W END AVE
Mailing Address - Street 2:APT.. 12-A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5469
Mailing Address - Country:US
Mailing Address - Phone:646-221-8944
Mailing Address - Fax:212-233-8348
Practice Address - Street 1:360 W 125TH ST
Practice Address - Street 2:SUITE 8
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-4801
Practice Address - Country:US
Practice Address - Phone:646-221-8944
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-14
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046957261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02207707Medicaid