Provider Demographics
NPI:1871981068
Name:CREATIVE DENTAL OF QUEENS
Entity type:Organization
Organization Name:CREATIVE DENTAL OF QUEENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TIMUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MOZNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-459-4700
Mailing Address - Street 1:63-58 WETHEROLE STREET
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374
Mailing Address - Country:US
Mailing Address - Phone:718-459-4700
Mailing Address - Fax:914-390-9111
Practice Address - Street 1:63-58 WETHEROLE STREET
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374
Practice Address - Country:US
Practice Address - Phone:718-459-4700
Practice Address - Fax:914-390-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048393261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental