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General NPI Number Information
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NPI Number | 1366979775
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Entity Type | Organization
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Legal Business Name | YOUR SMILE DENTAL OF RIVERHEAD
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Dates
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Enumeration Date | 05/16/2017
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Last Update Date | 05/16/2017
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Provider Practice Location Address
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Address Line | 177 OLD COUNTRY RD STE 1
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City | RIVERHEAD
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State | NY
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Zip | 11901-2102
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Country | US
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Telephone | 631-462-0300
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Fax |
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Provider Business Mailing Address
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Address Line | 6040 JERICHO TPKE
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City | COMMACK
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State | NY
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Zip | 11725-2806
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Country | US
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Telephone | 631-462-0300
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | VICTOR KATSMAN
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Credential |
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Telephone | 516-302-7372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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