1265520399 NPI number — MERRICK ORAL SURGERY PLLC

Table of content: (NPI 1265520399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265520399 NPI number — MERRICK ORAL SURGERY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERRICK ORAL SURGERY 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:
Provider Other Organization Name Type Code:
6
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:
1265520399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2116 MERRICK AVE SUITE 4008.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERRICK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-546-1444
Provider Business Mailing Address Fax Number:
516-546-5576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2116 MERRICK AVE
Provider Second Line Business Practice Location Address:
SUITE 4008
Provider Business Practice Location Address City Name:
MERRICK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-546-1444
Provider Business Practice Location Address Fax Number:
516-546-5576
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DABUNDO
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
516-546-1444

Provider Taxonomy Codes

  • Taxonomy code: 204E00000X , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0106X , 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: 00389937 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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