1265423354 NPI number — NORTH FORK DENTAL ASSOCIATES PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265423354 NPI number — NORTH FORK DENTAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH FORK DENTAL ASSOCIATES PC
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:
1265423354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 749
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MATTITUCK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11952-0749
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-298-9168
Provider Business Mailing Address Fax Number:
631-298-5728

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7555 MAIN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTITUCK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11952-1516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-298-9168
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REDMOND
Authorized Official First Name:
PETER
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
OWNER/DOCTOR
Authorized Official Telephone Number:
631-298-9168

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  049170 , 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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