Healthcare Provider Details

I. General information

NPI: 1306201066
Provider Name (Legal Business Name): LONG ISLAND ORAL SURGERY ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NORTHERN BLVD SUITE 180
GREAT NECK NY
11021-5338
US

IV. Provider business mailing address

959 BRUSH HOLLOW RD SUITE 102
WESTBURY NY
11590-1778
US

V. Phone/Fax

Practice location:
  • Phone: 516-487-4100
  • Fax: 516-487-4041
Mailing address:
  • Phone: 516-333-5900
  • Fax: 516-333-5868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number041527
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number044656
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number057517-1
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number052978
License Number StateNY

VIII. Authorized Official

Name: MRS. KATHY LARSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 516-487-4100