Provider Demographics
NPI:1114936929
Name:WANTAGH DENTAL ARTS, PC
Entity Type:Organization
Organization Name:WANTAGH DENTAL ARTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOERTDOERFER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-679-7978
Mailing Address - Street 1:PO BOX 7485
Mailing Address - Street 2:
Mailing Address - City:WANTAGH
Mailing Address - State:NY
Mailing Address - Zip Code:11793-0485
Mailing Address - Country:US
Mailing Address - Phone:516-679-7978
Mailing Address - Fax:516-826-5830
Practice Address - Street 1:1228 WANTAGH AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WANTAGH
Practice Address - State:NY
Practice Address - Zip Code:11793-2209
Practice Address - Country:US
Practice Address - Phone:516-679-7978
Practice Address - Fax:516-826-5830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044865122300000X
NY051494122300000X
NY0491861223P0300X
NY016591124Q00000X
NY022088124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty