Healthcare Provider Details

I. General information

NPI: 1124346887
Provider Name (Legal Business Name): PETER MICHAEL KOBLAN III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 LARKFIELD RD SUITE 107
EAST NORTHPORT NY
11731-4205
US

IV. Provider business mailing address

554 LARKFIELD RD SUITE 107
EAST NORTHPORT NY
11731-4205
US

V. Phone/Fax

Practice location:
  • Phone: 631-368-2660
  • Fax: 631-368-2668
Mailing address:
  • Phone: 631-368-2660
  • Fax: 631-368-2668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number046284
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: