Provider Demographics
NPI:1730337577
Name:QUEENS VILLAGE DENTAL ASSOCIATES PC
Entity type:Organization
Organization Name:QUEENS VILLAGE DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:FLAX
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-464-9216
Mailing Address - Street 1:221-10 JAMAICA A.
Mailing Address - Street 2:SUITE 103
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428
Mailing Address - Country:US
Mailing Address - Phone:718-464-9216
Mailing Address - Fax:718-464-3953
Practice Address - Street 1:221-10 JAMAICA A.
Practice Address - Street 2:SUITE 103
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428
Practice Address - Country:US
Practice Address - Phone:718-464-9216
Practice Address - Fax:718-464-3953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-05
Last Update Date:2017-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043437122300000X
NY043393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty