Healthcare Provider Details

I. General information

NPI: 1407217870
Provider Name (Legal Business Name): PANOSSIAN ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5240 MERRICK RD SUITE 1
MASSAPEQUA NY
11758-6207
US

IV. Provider business mailing address

5240 MERRICK RD SUITE 1
MASSAPEQUA NY
11758-6207
US

V. Phone/Fax

Practice location:
  • Phone: 516-541-4767
  • Fax: 516-541-4769
Mailing address:
  • Phone: 516-541-4767
  • Fax: 516-541-4769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number051170
License Number StateNY

VIII. Authorized Official

Name: MR. GREG PANOSSIAN
Title or Position: ORAL SURGEON
Credential:
Phone: 516-541-4767