Basic Information
| Provider Information | |||||||||
| NPI: | 1003807975 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRUKARTZ | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JEFFREY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11034 73RD RD | ||||||||
| Address2: | |||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113756322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1718263816 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 585 SCHENECTADY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112031809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186045000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 04/11/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0404331 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02514529 | 05 | NY | MEDICAID |