Provider Demographics
NPI:1609093905
Name:NANUET MALL DENTAL, P.C.
Entity type:Organization
Organization Name:NANUET MALL DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHRAPKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:845-624-7500
Mailing Address - Street 1:75 W ROUTE 59
Mailing Address - Street 2:SUITE# 1009A
Mailing Address - City:NANUET
Mailing Address - State:NY
Mailing Address - Zip Code:10954-2700
Mailing Address - Country:US
Mailing Address - Phone:845-624-7500
Mailing Address - Fax:845-624-7505
Practice Address - Street 1:75 W ROUTE 59
Practice Address - Street 2:SUITE# 1009A
Practice Address - City:NANUET
Practice Address - State:NY
Practice Address - Zip Code:10954-2700
Practice Address - Country:US
Practice Address - Phone:845-624-7500
Practice Address - Fax:845-624-7505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0490591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02550030Medicaid