Provider Demographics
NPI:1164732392
Name:SOUTH NASSAU DENTAL ARTS PC
Entity Type:Organization
Organization Name:SOUTH NASSAU DENTAL ARTS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/C.E.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHOUKRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-763-4500
Mailing Address - Street 1:85 NORTH PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-4105
Mailing Address - Country:US
Mailing Address - Phone:516-763-4500
Mailing Address - Fax:516-763-4502
Practice Address - Street 1:85 NORTH PARK AVENUE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-4105
Practice Address - Country:US
Practice Address - Phone:516-763-4500
Practice Address - Fax:516-763-4502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03185119Medicaid