Provider Demographics
NPI:1174629521
Name:ADVANCED DENTAL & ORAL SURGERY
Entity Type:Organization
Organization Name:ADVANCED DENTAL & ORAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMBIZ
Authorized Official - Middle Name:ALI
Authorized Official - Last Name:ZANGENEH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:845-569-2000
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:VAILS GATE
Mailing Address - State:NY
Mailing Address - Zip Code:12584-0444
Mailing Address - Country:US
Mailing Address - Phone:845-569-2000
Mailing Address - Fax:845-569-4950
Practice Address - Street 1:401 WINDSOR HIGHWAY
Practice Address - Street 2:
Practice Address - City:VAILS GATE
Practice Address - State:NY
Practice Address - Zip Code:12584
Practice Address - Country:US
Practice Address - Phone:845-569-2000
Practice Address - Fax:845-569-4950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041119122300000X
NY042635122300000X
NY048694122300000X
NY0487011223E0200X
NY0524031223P0300X
NY0405181223S0112X
NY0450971223S0112X
NY0371641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty