Provider Demographics
NPI:1124198718
Name:WEST BABYLON DENTAL
Entity Type:Organization
Organization Name:WEST BABYLON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:TARDERA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-664-6067
Mailing Address - Street 1:393 SUNRISE HWY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704
Mailing Address - Country:US
Mailing Address - Phone:631-669-6067
Mailing Address - Fax:631-661-8792
Practice Address - Street 1:393 SUNRISE HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704
Practice Address - Country:US
Practice Address - Phone:631-669-6067
Practice Address - Fax:631-661-8792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty