Healthcare Provider Details

I. General information

NPI: 1407118540
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF SUFFOLK COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 JERICHO TPKE SUITE 145
COMMACK NY
11725-2937
US

IV. Provider business mailing address

2171 JERICHO TPKE SUITE 145
COMMACK NY
11725-2937
US

V. Phone/Fax

Practice location:
  • Phone: 631-486-6364
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number053854-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number054175
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number050315
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL IOANNOU
Title or Position: PEDIATRIC DENTIST
Credential:
Phone: 631-486-6364