=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982739314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARRY L. BEHRENSDDS FRED GOODSTEINDDSPC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1575 BROADWAY STE. 1
-----------------------------------------------------
City | HEWLETT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11557-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-295-3090
-----------------------------------------------------
Fax | 516-374-7172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1575 BROADWAY STE. 1
-----------------------------------------------------
City | HEWLETT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11557-1428
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-295-3090
-----------------------------------------------------
Fax | 516-374-7172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DR. BARRY L. BEHRENS
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 516-295-3090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------