1265876726 NPI number — ISLAND PEDIATRIC DENTISTRY 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 1265876726 NPI number — ISLAND PEDIATRIC DENTISTRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ISLAND PEDIATRIC DENTISTRY 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:
1265876726
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1300 UNION TPKE STE 307
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HYDE PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11040-1759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 UNION TPKE STE 307
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW HYDE PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11040-1759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-409-3753
Provider Business Practice Location Address Fax Number:
866-357-0569
Provider Enumeration Date:
04/26/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SEO
Authorized Official First Name:
SARA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
646-409-3753

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  054536 , 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)