Healthcare Provider Details

I. General information

NPI: 1184115859
Provider Name (Legal Business Name): PREMIER ENDODONTICS OF PATCHOGUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2018
Last Update Date: 05/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 MEDFORD AVENUE
PATCHOGUE NY
11772
US

IV. Provider business mailing address

44 MEDFORD AVENUE
PATCHOGUE NY
11772
US

V. Phone/Fax

Practice location:
  • Phone: 631-447-6060
  • Fax: 631-447-7088
Mailing address:
  • Phone: 631-447-6060
  • Fax: 631-447-7088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. ASHISH SAHASRABUDHE
Title or Position: OWNER
Credential: D.M.D
Phone: 516-222-1822