MEDICARE: NY METRO DENTAL, PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1821622127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NY METRO DENTAL, PC

Provider Business Mailing Address
First Line	:	492 OLD TOWN RD
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2249
Country	:	US
Telephone Number	:	413-382-7022
Fax Number	:

Provider Business Practice Location Address
First Line	:	492 OLD TOWN RD
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-2249
Country	:	US
Telephone Number	:	413-382-7022
Fax Number	:

Authorized Official
Title or Position	:	REG. MGR
Name	:	AMY CADIEUX
Credential	:
Telephone Number	:	413-382-7022

Provider Enumeration Date	:	02/25/2020
Last Update Date	:	02/25/2020

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