Provider Demographics
NPI:1023155470
Name:GALLERIA MALL DENTAL PC
Entity type:Organization
Organization Name:GALLERIA MALL DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRASNOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:914-997-9000
Mailing Address - Street 1:100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-2601
Mailing Address - Country:US
Mailing Address - Phone:914-997-9000
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-2601
Practice Address - Country:US
Practice Address - Phone:914-997-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0460431223G0001X
NY0526741223G0001X
NY0521191223G0001X
NY0501481223G0001X
NY0521121223G0001X
NY0487601223P0221X
NY0427071223P0300X
NY0481851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02598167Medicaid