=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578841672
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAMPTON PEDIATRIC DENTAL ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2011
-----------------------------------------------------
Last Update Date | 07/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 97 N MAIN ST
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11968-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-287-8687
-----------------------------------------------------
Fax | 631-204-1430
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 97 N MAIN ST
-----------------------------------------------------
City | SOUTHAMPTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11968-3300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-287-8687
-----------------------------------------------------
Fax | 631-204-1430
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NANCY ELIZABETH COSENZA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 631-287-8687
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 043391
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------