Provider Demographics
NPI:1487869749
Name:BELL BLVD. DENTAL, P.C.
Entity type:Organization
Organization Name:BELL BLVD. DENTAL, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JUN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MMSC
Authorized Official - Phone:718-281-2222
Mailing Address - Street 1:46-01 BELL BLVD.
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361
Mailing Address - Country:US
Mailing Address - Phone:718-281-2222
Mailing Address - Fax:718-281-2822
Practice Address - Street 1:46-01 BELL BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361
Practice Address - Country:US
Practice Address - Phone:718-281-2222
Practice Address - Fax:718-281-2822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0477471223G0001X
NY0546881223G0001X
NY0489581223P0700X
NY0482111223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty