=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568679389
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER LAURENCE ROSENTHAL D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1254 MONTAUK HWY
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-4924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-669-9194
-----------------------------------------------------
Fax | 631-587-7911
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1254 MONTAUK HWY
-----------------------------------------------------
City | WEST ISLIP
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11795-4924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-669-9194
-----------------------------------------------------
Fax | 631-587-7911
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 031883
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------