Provider Demographics
NPI:1114133345
Name:PURE DENTAL OF LONG ISLAND PC
Entity Type:Organization
Organization Name:PURE DENTAL OF LONG ISLAND PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:OBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-663-0955
Mailing Address - Street 1:496 COUNTY ROAD 111
Mailing Address - Street 2:BUILDING F
Mailing Address - City:MANORVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11949
Mailing Address - Country:US
Mailing Address - Phone:631-929-5855
Mailing Address - Fax:631-886-1971
Practice Address - Street 1:496 COUNTY ROAD 111
Practice Address - Street 2:BUILDING F
Practice Address - City:MANORVILLE
Practice Address - State:NY
Practice Address - Zip Code:11949
Practice Address - Country:US
Practice Address - Phone:631-929-5855
Practice Address - Fax:631-886-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty