1508195975 NPI number — RODNEY RASTEGAR DDS PLLC

Table of content: (NPI 1508195975)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508195975 NPI number — RODNEY RASTEGAR DDS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RODNEY RASTEGAR DDS PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PROGRESSIVE ORAL SURGERY OF LONG ISLAND
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508195975
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23 BOND STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREAT NECK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-482-0329
Provider Business Mailing Address Fax Number:
516-482-0401

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 FRANKLIN AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
GARDEN CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-741-4415
Provider Business Practice Location Address Fax Number:
516-741-4417
Provider Enumeration Date:
12/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
DAVILA
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
516-741-4415

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  048692 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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