Healthcare Provider Details

I. General information

NPI: 1528699873
Provider Name (Legal Business Name): SIOMS FOREST HILLS MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2020
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 FROEHLICH FARM BLVD
WOODBURY NY
11797-2906
US

IV. Provider business mailing address

167 FROEHLICH FARM BLVD
WOODBURY NY
11797-2906
US

V. Phone/Fax

Practice location:
  • Phone: 516-677-9777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: STEVE YUSUPOV
Title or Position: MANAGING PARTNER
Credential: MD, DDS
Phone: 516-677-9777