Provider Demographics
NPI:1538539986
Name:EAST SIDE PEDIATRIC DENTAL
Entity type:Organization
Organization Name:EAST SIDE PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LOO
Authorized Official - Last Name:MARN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:212-965-8113
Mailing Address - Street 1:128 MOTT STREET
Mailing Address - Street 2:SUITE 403
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-5575
Mailing Address - Country:US
Mailing Address - Phone:212-965-8113
Mailing Address - Fax:212-965-8114
Practice Address - Street 1:133 EAST 58TH STREET
Practice Address - Street 2:SUITE 402
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1157
Practice Address - Country:US
Practice Address - Phone:212-965-8113
Practice Address - Fax:212-965-8114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty