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General NPI Number Information
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NPI Number | 1275622086
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Entity Type | Organization
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Legal Business Name | PERIODONTAL & IMPLANT SURGERY ASSOCIATES
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Dates
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Enumeration Date | 10/11/2006
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Last Update Date | 08/11/2014
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Provider Practice Location Address
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Address Line | 393 FRANKLIN AVE SUITE 103
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City | FRANKLIN SQUARE
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State | NY
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Zip | 11010-1222
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Country | US
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Telephone | 516-354-5228
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Fax | 516-354-8006
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Provider Business Mailing Address
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Address Line | 393 FRANKLIN AVE SUITE 103
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City | FRANKLIN SQUARE
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State | NY
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Zip | 11010-1222
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Country | US
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Telephone | 516-354-5228
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Fax | 516-354-8006
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANTHONY IENNA
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Credential | DDS
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Telephone | 516-354-5228
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 040277
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License Number State | NY
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