Provider Demographics
NPI:1053322255
Name:ISLIP DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:ISLIP DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BOTTNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-581-2038
Mailing Address - Street 1:375 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751
Mailing Address - Country:US
Mailing Address - Phone:631-581-2038
Mailing Address - Fax:631-224-1322
Practice Address - Street 1:375 MAIN STREET
Practice Address - Street 2:
Practice Address - City:ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11751
Practice Address - Country:US
Practice Address - Phone:631-581-2038
Practice Address - Fax:631-224-1322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04263011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty