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General NPI Number Information
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NPI Number | 1487302006
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Entity Type | Organization
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Legal Business Name | MODERN DENTISTRY OF LONG ISLAND
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Dates
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Enumeration Date | 03/13/2022
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Last Update Date | 03/13/2022
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Provider Practice Location Address
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Address Line | 714 MAIN ST
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-2223
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Country | US
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Telephone | 631-473-0582
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Fax |
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Provider Business Mailing Address
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Address Line | 5 DOYLE CT
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City | PORT JEFFERSON
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State | NY
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Zip | 11777-1167
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Country | US
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Telephone | 631-560-9536
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. HILSHA CARRION
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Credential | DMD
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Telephone | 631-473-0582
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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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