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General NPI Number Information
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NPI Number | 1720766868
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Entity Type | Organization
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Legal Business Name | SOUTH FORK FAMILY DENTISTRY PC
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Dates
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Enumeration Date | 07/10/2023
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Last Update Date | 07/10/2023
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Provider Practice Location Address
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Address Line | 426 MONTAUK HWY
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City | EAST QUOGUE
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State | NY
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Zip | 11942-3952
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Country | US
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Telephone | 631-653-4479
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Fax |
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Provider Business Mailing Address
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Address Line | 4 SCHEYER CT
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City | MEDFORD
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State | NY
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Zip | 11763-3022
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. VICTORIA ELENA SHACK
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Credential | DDS
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Telephone | 917-324-7927
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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