Healthcare Provider Details

I. General information

NPI: 1710060223
Provider Name (Legal Business Name): LONG ISLAND ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 VANDERVENTER AVE STE 260
PORT WASHINGTON NY
11050-3737
US

IV. Provider business mailing address

14 VANDERVENTER AVE STE 260
PORT WASHINGTON NY
11050-3737
US

V. Phone/Fax

Practice location:
  • Phone: 516-944-8330
  • Fax: 516-883-1598
Mailing address:
  • Phone: 516-944-8330
  • Fax: 516-883-1598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. DEBRA MCQUILLAN
Title or Position: MANAGER
Credential:
Phone: 516-294-9696