Provider Demographics
NPI:1548685357
Name:IDEAL SMILE DENTAL, P.C.
Entity type:Organization
Organization Name:IDEAL SMILE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YURI
Authorized Official - Middle Name:
Authorized Official - Last Name:RESHETNIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-205-2055
Mailing Address - Street 1:PO BOX 740059
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-0059
Mailing Address - Country:US
Mailing Address - Phone:718-205-2055
Mailing Address - Fax:718-205-2355
Practice Address - Street 1:9123 QUEENS BLVD # B
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-5531
Practice Address - Country:US
Practice Address - Phone:718-205-2055
Practice Address - Fax:718-205-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0506161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02457909Medicaid
NYBR-8509513OtherDEA