=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992384457
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUSANNA ISAACS DDS, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2021
-----------------------------------------------------
Last Update Date | 04/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 143 MINEOLA AVE
-----------------------------------------------------
City | ROSLYN HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-510-2255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 54-40 LITTLE NECK PKWY APT#3F
-----------------------------------------------------
City | LITTLE NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-510-2255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. SUSANNA ISAACS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-510-2255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------