Healthcare Provider Details

I. General information

NPI: 1740438258
Provider Name (Legal Business Name): AMERICAN ORTHODONTIC ASSOCIATES OF WEST ISLIP,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 MONTAUK HWY
WEST ISLIP NY
11795-4909
US

IV. Provider business mailing address

1145 MONTAUK HWY
WEST ISLIP NY
11795-4909
US

V. Phone/Fax

Practice location:
  • Phone: 631-661-3025
  • Fax: 631-661-2095
Mailing address:
  • Phone: 631-661-3025
  • Fax: 631-661-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number046229-1
License Number StateNY

VIII. Authorized Official

Name: DR. JOSEPH MICHAEL VITAGLIANO
Title or Position: PRESIDENT
Credential: DMD
Phone: 631-661-3025