Healthcare Provider Details

I. General information

NPI: 1093573529
Provider Name (Legal Business Name): DANIEL OMID BAKHADJ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STONY BROOK SCHOOL OF DENTAL MEDICINE 114 ROCKLAND HALL
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

62 LAKE AVE S STE A
NESCONSET NY
11767-1094
US

V. Phone/Fax

Practice location:
  • Phone: 631-632-3181
  • Fax:
Mailing address:
  • Phone: 516-440-3805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number065656
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: