Healthcare Provider Details

I. General information

NPI: 1922838432
Provider Name (Legal Business Name): GOLD COAST ORAL AND MAXILLOFACIAL SURGERY SYOSSET PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 UNDERHILL BLVD
SYOSSET NY
11791-3490
US

IV. Provider business mailing address

55 BRYANT AVE, SUITE 2
ROSLYN NY
11576
US

V. Phone/Fax

Practice location:
  • Phone: 516-744-6262
  • Fax: 516-744-6262
Mailing address:
  • Phone: 516-749-3000
  • Fax: 516-749-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STEVE YUSUPOV
Title or Position: OWNER
Credential: DDS, MD
Phone: 516-749-3000