1770705766 NPI number — STONY BROOK FAMILY DENTISTRY PC

Table of content: (NPI 1770705766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770705766 NPI number — STONY BROOK FAMILY DENTISTRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONY BROOK FAMILY 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:
1770705766
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
207 HALLOCK RD
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
STONY BROOK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11790-3033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-751-7645
Provider Business Mailing Address Fax Number:
631-751-4170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 HALLOCK RD
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
STONY BROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11790-3033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-751-7645
Provider Business Practice Location Address Fax Number:
631-751-4170
Provider Enumeration Date:
05/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BAUM
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
631-751-7645

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  046703 , 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: 047430 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 048062 , 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)