Provider Demographics
NPI:1306201066
Name:LONG ISLAND ORAL SURGERY ASSOCIATES, PC
Entity Type:Organization
Organization Name:LONG ISLAND ORAL SURGERY ASSOCIATES, PC
Other - Org Name:LONG ISLAND CENTER FOR ORAL AND MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-487-4100
Mailing Address - Street 1:959 BRUSH HOLLOW RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1778
Mailing Address - Country:US
Mailing Address - Phone:516-333-5900
Mailing Address - Fax:516-333-5868
Practice Address - Street 1:1000 NORTHERN BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5338
Practice Address - Country:US
Practice Address - Phone:516-487-4100
Practice Address - Fax:516-487-4041
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONG ISLAND ORAL SURGERY ASSOCIATES, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0529781223S0112X
NY0415271223S0112X
NY0446561223S0112X
NY057517-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty