Healthcare Provider Details

I. General information

NPI: 1609915883
Provider Name (Legal Business Name): SUFFOLK PEDIATRIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 10/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 MEDICAL DRIVE
PORT JEFFERSON STATION NY
11776
US

IV. Provider business mailing address

8 MEDICAL DRIVE
PORT JEFFERSON STATION NY
11776
US

V. Phone/Fax

Practice location:
  • Phone: 631-928-8585
  • Fax: 631-928-8861
Mailing address:
  • Phone: 631-928-8585
  • Fax: 631-928-8861

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. ROBERT SERINO
Title or Position: PRESIDENT
Credential: DDS
Phone: 631-928-8585