Provider Demographics
NPI:1073729380
Name:THE WISDOM TOOTH OF COMMACK
Entity Type:Organization
Organization Name:THE WISDOM TOOTH OF COMMACK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KANTROWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-462-0300
Mailing Address - Street 1:6040 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2806
Mailing Address - Country:US
Mailing Address - Phone:631-462-0300
Mailing Address - Fax:631-462-0347
Practice Address - Street 1:6040 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2806
Practice Address - Country:US
Practice Address - Phone:631-462-0300
Practice Address - Fax:631-462-0347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0356541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty