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General NPI Number Information
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NPI Number | 1083898183
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Entity Type | Organization
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Legal Business Name | STONY BROOK COSMETIC DENTISTRY, P.C.
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Dates
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Enumeration Date | 12/26/2007
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Last Update Date | 12/26/2007
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Provider Practice Location Address
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Address Line | 215 HALLOCK RD SUITE 2
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City | STONY BROOK
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State | NY
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Zip | 11790-3078
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Country | US
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Telephone | 631-689-3226
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Fax | 631-689-3155
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Provider Business Mailing Address
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Address Line | 215 HALLOCK ROAD SUITE 2
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City | STONY BROOK
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State | NY
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Zip | 11790-3078
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Country | US
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Telephone | 631-689-3226
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Fax | 631-689-3155
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. KEITH V WATKINS
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Credential | D.D.S.
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Telephone | 631-689-3226
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 034701
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License Number State | NY
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