Basic Information
| Provider Information | |||||||||
| NPI: | 1548451933 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STARRETT CITY DENTAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1390 PENNSYLVANIA AVENUE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186428600 | ||||||||
| FaxNumber: | 7189421425 | ||||||||
| Practice Location | |||||||||
| Address1: | 1390 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112392103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186428600 | ||||||||
| FaxNumber: | 7189421425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2007 | ||||||||
| LastUpdateDate: | 08/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | STROPNSKY | ||||||||
| AuthorizedOfficialFirstName: | MELVYN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7186428600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STARRETT CITY DENTAL GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 026132 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 00396272 | 05 | NY | MEDICAID |