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General NPI Number Information
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NPI Number | 1407118540
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY OF SUFFOLK COUNTY
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Dates
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Enumeration Date | 06/14/2012
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Last Update Date | 06/14/2012
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Provider Practice Location Address
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Address Line | 2171 JERICHO TPKE SUITE 145
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City | COMMACK
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State | NY
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Zip | 11725-2937
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Country | US
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Telephone | 631-486-6364
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Fax |
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Provider Business Mailing Address
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Address Line | 2171 JERICHO TPKE SUITE 145
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City | COMMACK
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State | NY
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Zip | 11725-2937
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. MICHAEL IOANNOU
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Credential |
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Telephone | 631-486-6364
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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 | 053854-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 054175
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 050315
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License Number State | NY
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