Basic Information
| Provider Information | |||||||||
| NPI: | 1962691220 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRUMP VILLAGE DENTAL P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 NEPTUNE AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112244004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189468585 | ||||||||
| FaxNumber: | 7189463230 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 NEPTUNE AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112244004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189468585 | ||||||||
| FaxNumber: | 7189463230 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2007 | ||||||||
| LastUpdateDate: | 10/23/2007 | ||||||||
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| AuthorizedOfficialLastName: | RIPA | ||||||||
| AuthorizedOfficialFirstName: | VYACHESLAV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7189468585 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.D.S, PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 02227829 | 05 | NY | MEDICAID |