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General NPI Number Information
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NPI Number | 1497289037
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Entity Type | Organization
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Legal Business Name | STONY BROOK ORAL AND FACIAL SURGERY PC
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Dates
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Enumeration Date | 04/19/2017
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Last Update Date | 02/29/2024
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Provider Practice Location Address
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Address Line | 207 HALLOCK RD SUITE 2
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City | STONY BROOK
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State | NY
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Zip | 11790-3033
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Country | US
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Telephone | 631-675-9601
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Fax | 631-675-9602
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Provider Business Mailing Address
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Address Line | 207 HALLOCK RD SUITE 2
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City | STONY BROOK
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State | NY
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Zip | 11790-3033
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Country | US
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Telephone | 631-675-9601
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Fax | 631-675-9602
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL PROOTHI
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Credential | DMD, MD
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Telephone | 631-675-9601
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 051735-1
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License Number State | NY
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