Basic Information
| Provider Information | |||||||||
| NPI: | 1073919973 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPEN DOOR FAMILY MEDICAL CENTER SCHOOL BASED MOBILE DENTAL VAN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | OPEN DOOR FAMILY MEDICAL CENTERS, INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 165 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OSSINING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105624702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149377817 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 165 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OSSINING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105624702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149411263 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2014 | ||||||||
| LastUpdateDate: | 11/05/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAZZOTTA | ||||||||
| AuthorizedOfficialFirstName: | MARIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9145021470 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OPEN DOOR FAMILY MEDICAL CENTERS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 5905200R | NY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.