Provider Demographics
NPI:1114160207
Name:PETER H PRUDEN, D.D.S., P.C
Entity Type:Organization
Organization Name:PETER H PRUDEN, D.D.S., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:H
Authorized Official - Last Name:PRUDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-421-2471
Mailing Address - Street 1:124 MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-6922
Mailing Address - Country:US
Mailing Address - Phone:631-421-2471
Mailing Address - Fax:631-547-6809
Practice Address - Street 1:124 MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-6922
Practice Address - Country:US
Practice Address - Phone:631-421-2471
Practice Address - Fax:631-547-6809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0346611223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty