Healthcare Provider Details

I. General information

NPI: 1831361054
Provider Name (Legal Business Name): PM DENTAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2008
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 BAYSHORE RD
DEER PARK NY
11729-6930
US

IV. Provider business mailing address

299 CANDLEWOOD PATH
DIX HILLS NY
11746-8003
US

V. Phone/Fax

Practice location:
  • Phone: 631-748-6136
  • Fax:
Mailing address:
  • Phone: 631-748-6136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number037149
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number041974
License Number StateNY

VIII. Authorized Official

Name: PAUL HENNIS
Title or Position: DENTIST
Credential:
Phone: 718-723-4878