Healthcare Provider Details

I. General information

NPI: 1790846798
Provider Name (Legal Business Name): SANFORD J KOWAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 EAST PARK AVE
LONG BEACH NY
11561
US

IV. Provider business mailing address

622 EAST PARK AVE
LONG BEACH NY
11561
US

V. Phone/Fax

Practice location:
  • Phone: 516-432-5195
  • Fax: 516-487-1253
Mailing address:
  • Phone: 516-432-5195
  • Fax: 516-487-1253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number027941NEWYORK
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: