Healthcare Provider Details

I. General information

NPI: 1174629521
Provider Name (Legal Business Name): ADVANCED DENTAL & ORAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 WINDSOR HIGHWAY
VAILS GATE NY
12584
US

IV. Provider business mailing address

PO BOX 444
VAILS GATE NY
12584-0444
US

V. Phone/Fax

Practice location:
  • Phone: 845-569-2000
  • Fax: 845-569-4950
Mailing address:
  • Phone: 845-569-2000
  • Fax: 845-569-4950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number042635
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number048694
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number048701
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number052403
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number040518
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number045097
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number037164
License Number StateNY
# 8
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number041119
License Number StateNY

VIII. Authorized Official

Name: DR. KAMBIZ ALI ZANGENEH
Title or Position: OWNER
Credential: DMD
Phone: 845-569-2000