Healthcare Provider Details

I. General information

NPI: 1629159116
Provider Name (Legal Business Name): EXCELDENT DENTAL OF COMMACK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 VETS MEM HWY STE 2
COMMACK NY
11725
US

IV. Provider business mailing address

77 VETS MEM HWY STE 2
COMMACK NY
11725
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-5663
  • Fax: 631-368-4325
Mailing address:
  • Phone: 631-499-5663
  • Fax: 631-368-4325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. HADI ZIAEI
Title or Position: OWNER
Credential: DDS
Phone: 631-499-5663