Healthcare Provider Details

I. General information

NPI: 1508011305
Provider Name (Legal Business Name): ALL COUNTY ORAL & MAXILLOFACIAL SURGERY LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2008
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 BROADHOLLOW RD SUITE 200
MELVILLE NY
11747-4701
US

IV. Provider business mailing address

115 BROADHOLLOW RD STE 200
MELVILLE NY
11747-4915
US

V. Phone/Fax

Practice location:
  • Phone: 631-752-1033
  • Fax: 631-752-1034
Mailing address:
  • Phone: 631-752-1033
  • Fax: 631-752-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. ROSS O CHAVKIN
Title or Position: OWNER
Credential: D.D.S.
Phone: 631-752-1033