1639353345 NPI number — PM DENTAL SERVICES P.C.

Table of content: (NPI 1639353345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639353345 NPI number — PM DENTAL SERVICES P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PM DENTAL SERVICES P.C.
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:
1639353345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
299 CANDLEWOOD PATH
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIX HILLS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11746-8003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-748-6136
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23520 147TH AVE
Provider Second Line Business Practice Location Address:
SUITE# 3
Provider Business Practice Location Address City Name:
ROSEDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11422-3293
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-723-4878
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HENNIS
Authorized Official First Name:
PAUL
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
631-748-6136

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  037149 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 041974 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 01109815 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00739359 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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