Healthcare Provider Details

I. General information

NPI: 1366613317
Provider Name (Legal Business Name): STATION DENTAL ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 OLD COUNTRY RD
RIVERHEAD NY
11901-2102
US

IV. Provider business mailing address

177 OLD COUNTRY RD
RIVERHEAD NY
11901-2102
US

V. Phone/Fax

Practice location:
  • Phone: 631-208-3068
  • Fax: 631-208-3137
Mailing address:
  • Phone: 631-208-3068
  • Fax: 631-208-3137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number039610
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number045455
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number039610
License Number StateNY

VIII. Authorized Official

Name: MR. SHELDON GARY MILO
Title or Position: OWNER
Credential: DDS
Phone: 516-448-4652