=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831918879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIAN S. MARGOLIS DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2024
-----------------------------------------------------
Last Update Date | 10/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 333 GLEN HEAD RD SUITE # 170
-----------------------------------------------------
City | OLD BROOKVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-484-4741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 GLEN HEAD RD SUITE # 170
-----------------------------------------------------
City | OLD BROOKVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR CREDENTIALING TEAM LEAD
-----------------------------------------------------
Name | JENNY GARCIA-ROCHA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 972-869-3789
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------