Healthcare Provider Details

I. General information

NPI: 1417087156
Provider Name (Legal Business Name): LONG ISLAND ORTHODONTIC ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CLARK AVE
MASSAPEQUA NY
11758-4950
US

IV. Provider business mailing address

100 CLARK AVE
MASSAPEQUA NY
11758-4950
US

V. Phone/Fax

Practice location:
  • Phone: 516-541-9396
  • Fax: 516-541-9510
Mailing address:
  • Phone: 516-541-9396
  • Fax: 516-541-9510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number037943
License Number StateNY

VIII. Authorized Official

Name: MARY BUATTI ROMEO
Title or Position: PRESIDENT
Credential: DMD
Phone: 516-541-9396