Provider Demographics
NPI:1538770672
Name:BAYSIDE ORTHODONTICS PLLC
Entity type:Organization
Organization Name:BAYSIDE ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:INNA
Authorized Official - Middle Name:
Authorized Official - Last Name:GELLERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-631-0508
Mailing Address - Street 1:208-54 CROSS ISLAND PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360
Mailing Address - Country:US
Mailing Address - Phone:718-631-0508
Mailing Address - Fax:718-631-0509
Practice Address - Street 1:208-54 CROSS ISLAND PARKWAY
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360
Practice Address - Country:US
Practice Address - Phone:718-631-0508
Practice Address - Fax:718-631-0509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty