=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639514532
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DENNIS TAMBE BESONG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2013
-----------------------------------------------------
Last Update Date | 09/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34 COMMERCE AVE STE 1
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-727-1600
-----------------------------------------------------
Fax | 631-591-3488
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34 COMMERCE AVE STE 1
-----------------------------------------------------
City | RIVERHEAD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11901-3118
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-727-1600
-----------------------------------------------------
Fax | 631-591-3488
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME128732
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 89229
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 306028
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------