Provider Demographics
NPI:1093753758
Name:SUFFOLK ORAL SURGERY ASSOCIATES LLP
Entity Type:Organization
Organization Name:SUFFOLK ORAL SURGERY ASSOCIATES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-273-4888
Mailing Address - Street 1:601 SUFFOLK AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4309
Mailing Address - Country:US
Mailing Address - Phone:631-273-4888
Mailing Address - Fax:631-273-2398
Practice Address - Street 1:601 SUFFOLK AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4309
Practice Address - Country:US
Practice Address - Phone:631-273-4888
Practice Address - Fax:631-273-2398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0247191223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1093753758Medicare NSC