=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982089454
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROLINE RUBINO DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2015
-----------------------------------------------------
Last Update Date | 08/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4760 SUNRISE HWY
-----------------------------------------------------
City | MASSAPEQUA PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11762-2932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-541-2280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 70 JAYSON AVE
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021-4240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-355-8006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 057932
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------