Healthcare Provider Details

I. General information

NPI: 1871709097
Provider Name (Legal Business Name): TOTAL DENTAL CARE OF MIDDLE ISLAND P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 MIDDLE COUNTRY RD
MIDDLE ISLAND NY
11953-2510
US

IV. Provider business mailing address

699 MIDDLE COUNTRY RD
MIDDLE ISLAND NY
11953-2510
US

V. Phone/Fax

Practice location:
  • Phone: 631-924-8155
  • Fax: 631-345-5611
Mailing address:
  • Phone: 631-924-8155
  • Fax: 631-345-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: MRS. LIZ ANN JERMYN
Title or Position: OFFICE MANAGER
Credential:
Phone: 631-924-8155