Healthcare Provider Details

I. General information

NPI: 1265533343
Provider Name (Legal Business Name): MICHAEL T MAIORINO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 BROADWAY
AMITYVILLE NY
11701-2761
US

IV. Provider business mailing address

193 BROADWAY
AMITYVILLE NY
11701-2761
US

V. Phone/Fax

Practice location:
  • Phone: 631-598-2940
  • Fax:
Mailing address:
  • Phone: 631-598-2940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number050399
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: