Healthcare Provider Details

I. General information

NPI: 1487054938
Provider Name (Legal Business Name): SHORE SMILES DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 07/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 N BROADWAY
MASSAPEQUA NY
11758-2344
US

IV. Provider business mailing address

875 N BROADWAY
MASSAPEQUA NY
11758-2344
US

V. Phone/Fax

Practice location:
  • Phone: 516-797-0300
  • Fax:
Mailing address:
  • Phone: 516-797-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number055149
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number055149
License Number StateNY

VIII. Authorized Official

Name: DR. JIGAR S GANDHI
Title or Position: OWNER
Credential: DDS
Phone: 516-797-0300