MEDICARE: ISLAND ORTHODONTIC,PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	034366	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558439844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND ORTHODONTIC,PLLC

Provider Business Mailing Address
First Line	:	500 PORTION RD
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4587
Country	:	US
Telephone Number	:	631-588-1199
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 PORTION RD
Second Line	:
City	:	LAKE RONKONKOMA
State	:	NY
Zip	:	11779-4587
Country	:	US
Telephone Number	:	631-588-1199
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. SCOTT FRIEDMAN
Credential	:	DDS
Telephone Number	:	631-588-1199

Provider Enumeration Date	:	12/03/2006
Last Update Date	:	03/31/2017

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