MEDICARE: DR. KENNETH ALAN PATICOFF DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	043927	NY

General Provider Information

NPI Number	:	1174506976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH ALAN PATICOFF DDS

Provider Business Mailing Address
First Line	:	1992 DEER PARK AVE
Second Line	:
City	:	DEER PARK
State	:	NY
Zip	:	11729-2701
Country	:	US
Telephone Number	:	631-667-0004
Fax Number	:	631-667-3388

Provider Business Practice Location Address
First Line	:	1992 DEER PARK AVE
Second Line	:
City	:	DEER PARK
State	:	NY
Zip	:	11729-2701
Country	:	US
Telephone Number	:	631-667-0004
Fax Number	:	631-667-3388

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/25/2005
Last Update Date	:	07/08/2007

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