Healthcare Provider Details

I. General information

NPI: 1659362366
Provider Name (Legal Business Name): MICHAEL ANDREW IOANNOU D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 JERICHO TPKE STE 145
COMMACK NY
11725-2900
US

IV. Provider business mailing address

35 SPRINGWOOD PATH
SYOSSET NY
11791-1304
US

V. Phone/Fax

Practice location:
  • Phone: 631-486-6364
  • Fax:
Mailing address:
  • Phone: 917-568-4569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number050315
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: