1619249059 NPI number — NORTH SHORE ORAL SURGERY, LLC

Table of content: (NPI 1619249059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619249059 NPI number — NORTH SHORE ORAL SURGERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH SHORE ORAL SURGERY, LLC
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:
Provider Other Organization Name Type Code:
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:
1619249059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
285 MIDDLE COUNTRY RD
Provider Second Line Business Mailing Address:
SUITE #108
Provider Business Mailing Address City Name:
SMITHTOWN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11787-2978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-265-9700
Provider Business Mailing Address Fax Number:
631-265-9703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 MIDDLE COUNTRY RD
Provider Second Line Business Practice Location Address:
SUITE #108
Provider Business Practice Location Address City Name:
SMITHTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11787-2978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-265-9700
Provider Business Practice Location Address Fax Number:
631-265-9703
Provider Enumeration Date:
02/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
MONTAZEM
Authorized Official First Name:
ALEX
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
631-265-9700

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  042730 , 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)

  • Identifier: 521422P . This is a "HIP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0565561 . This is a "GHI MEDICAL" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 1364282 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: D99121 . This is a "EMPIRE BCBS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: P3492579 . This is a "OXFORD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 116561 . This is a "CIGNA DMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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