Healthcare Provider Details

I. General information

NPI: 1326310913
Provider Name (Legal Business Name): ARTISTIC DENTAL ASSOCIATES OF COMMACK LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6080 JERICHO TPKE SUITE 207
COMMACK NY
11725-2850
US

IV. Provider business mailing address

6080 JERICHO TPKE SUITE 207
COMMACK NY
11725-2850
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-1212
  • Fax: 631-499-2389
Mailing address:
  • Phone: 631-499-1212
  • Fax: 631-499-2389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number048534
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE KOROLOGOS
Title or Position: OWNER/DENTIST
Credential: DDS
Phone: 631-499-1212