Provider Demographics
NPI:1447671128
Name:BUSHWICK ORTHODONTICS PLLC
Entity type:Organization
Organization Name:BUSHWICK ORTHODONTICS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:OLEG
Authorized Official - Middle Name:
Authorized Official - Last Name:DRUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-373-6707
Mailing Address - Street 1:79 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11223-3551
Mailing Address - Country:US
Mailing Address - Phone:718-373-6707
Mailing Address - Fax:718-373-6799
Practice Address - Street 1:408 KNICKERBOCKER AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4102
Practice Address - Country:US
Practice Address - Phone:718-443-4444
Practice Address - Fax:718-373-6707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-23
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0472181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty