Healthcare Provider Details

I. General information

NPI: 1982991485
Provider Name (Legal Business Name): STEVE YUSUPOV DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: STEVE YUSUPOV DDS, MD

II. Dates (important events)

Enumeration Date: 07/05/2011
Last Update Date: 07/21/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 BRYANT AVE
ROSLYN NY
11576-1139
US

IV. Provider business mailing address

256-C MASON AVENUE 3RD FLOOR
STATEN ISLAND NY
10305-1851
US

V. Phone/Fax

Practice location:
  • Phone: 516-749-3000
  • Fax:
Mailing address:
  • Phone: 718-226-1251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number057086
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number285541
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: