Healthcare Provider Details

I. General information

NPI: 1568634624
Provider Name (Legal Business Name): WALTER HOMAYOON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2008
Last Update Date: 03/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 LANSON ST
BOHEMIA NY
11716-3403
US

IV. Provider business mailing address

669 LANSON ST
BOHEMIA NY
11716-3403
US

V. Phone/Fax

Practice location:
  • Phone: 631-567-4584
  • Fax: 631-567-3683
Mailing address:
  • Phone: 631-567-4584
  • Fax: 631-567-3683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number045053
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: