Provider Demographics
NPI:1548494826
Name:GENESIS DENTISTRY PC
Entity type:Organization
Organization Name:GENESIS DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-584-3826
Mailing Address - Street 1:375 E FORDHAM RD
Mailing Address - Street 2:2 FLOOR
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5033
Mailing Address - Country:US
Mailing Address - Phone:718-584-3826
Mailing Address - Fax:718-584-7309
Practice Address - Street 1:375 E FORDHAM RD
Practice Address - Street 2:2 FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5033
Practice Address - Country:US
Practice Address - Phone:718-584-3826
Practice Address - Fax:718-584-7309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045711-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty