Provider Demographics
NPI:1053827782
Name:YOUR SMILE DENTAL OF HAUPPAUGE
Entity Type:Organization
Organization Name:YOUR SMILE DENTAL OF HAUPPAUGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-413-2912
Mailing Address - Street 1:521 ROUTE 111 STE 106
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4358
Mailing Address - Country:US
Mailing Address - Phone:631-361-6605
Mailing Address - Fax:
Practice Address - Street 1:521 ROUTE 111 STE 106
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4358
Practice Address - Country:US
Practice Address - Phone:631-361-6605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03269418Medicaid