=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144407602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLOMBO DENTAL ASSOCIATES, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2008
-----------------------------------------------------
Last Update Date | 05/05/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 996 HICKSVILLE RD
-----------------------------------------------------
City | MASSAPEQUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11758-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-799-1787
-----------------------------------------------------
Fax | 516-799-2623
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 996 HICKSVILLE RD
-----------------------------------------------------
City | MASSAPEQUA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11758-1251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-799-1787
-----------------------------------------------------
Fax | 516-799-2623
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST / PARTNER
-----------------------------------------------------
Name | DR. FRED J COLOMBO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 516-799-1787
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 021404-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------