Healthcare Provider Details

I. General information

NPI: 1164806774
Provider Name (Legal Business Name): AMIR WASSIF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 MONTAUK HWY
WEST ISLIP NY
11795-4404
US

IV. Provider business mailing address

27 SHELLY CT
PLAINVIEW NY
11803-5309
US

V. Phone/Fax

Practice location:
  • Phone: 631-422-4000
  • Fax:
Mailing address:
  • Phone: 516-884-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number058956
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: