Healthcare Provider Details

I. General information

NPI: 1245527381
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF SUFFOLK COUNTY II
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3237 ROUTE 112 BUILDING #6 SUITE 7B
MEDFORD NY
11763-1424
US

IV. Provider business mailing address

3237 ROUTE 112 BUILDING #6 SUITE 7B
MEDFORD NY
11763-1424
US

V. Phone/Fax

Practice location:
  • Phone: 631-320-0880
  • Fax: 631-320-3165
Mailing address:
  • Phone: 631-320-0880
  • Fax: 631-320-3165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOS A IOANNOU
Title or Position: PEDIATRIC DENTIST
Credential: D.D.S.
Phone: 631-320-0880