Provider Demographics
NPI:1144639857
Name:IDEAL DENTAL IMPLANTS
Entity type:Organization
Organization Name:IDEAL DENTAL IMPLANTS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PANAGIOTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GLAVAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-487-6453
Mailing Address - Street 1:319 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-1510
Mailing Address - Country:US
Mailing Address - Phone:516-487-6453
Mailing Address - Fax:
Practice Address - Street 1:319 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-1510
Practice Address - Country:US
Practice Address - Phone:516-487-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDEAL DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-06
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047563261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental