=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922640911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUITE 2229 DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2019
-----------------------------------------------------
Last Update Date | 06/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 645 COMMACK RD
-----------------------------------------------------
City | COMMACK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11725-5401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-858-9800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 BROADWAY RM 1310
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10038-4365
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-587-0202
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP INSURANCE PLAN MANAGEMENT
-----------------------------------------------------
Name | MIKE COLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 727-424-2990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------