=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598914236
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMACK PEDIATRIC DENTAL ASSOC LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2008
-----------------------------------------------------
Last Update Date | 09/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 164 COMMACK RD. STE 4
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-499-2112
-----------------------------------------------------
Fax | 631-858-0586
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 164 COMMACK RD. STE 4
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-499-2112
-----------------------------------------------------
Fax | 631-858-0586
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/PARTNER
-----------------------------------------------------
Name | DR. ERIC GHERMAN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 631-499-2112
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 035281
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------