Healthcare Provider Details

I. General information

NPI: 1285776922
Provider Name (Legal Business Name): KENNETH A. PATICOFF, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1992 DEER PARK AVE
DEER PARK NY
11729-2701
US

IV. Provider business mailing address

1992 DEER PARK AVE
DEER PARK NY
11729-2701
US

V. Phone/Fax

Practice location:
  • Phone: 631-667-0004
  • Fax:
Mailing address:
  • Phone: 631-667-0004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH A PATICOFF
Title or Position: OWNER
Credential: DDS
Phone: 631-667-0004