Healthcare Provider Details

I. General information

NPI: 1891544102
Provider Name (Legal Business Name): ALLIANCE ORTHO SLEEP P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2931 GREY MOSS PASS
DULUTH GA
30097-6274
US

IV. Provider business mailing address

2437 ROCKVILLE CENTRE PKWY
OCEANSIDE NY
11572-1622
US

V. Phone/Fax

Practice location:
  • Phone: 631-374-3410
  • Fax:
Mailing address:
  • Phone: 516-640-7401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: KEVIN EATMON
Title or Position: MEDICAL DIRECTOR
Credential: DDS
Phone: 631-374-3410