Provider Demographics
NPI:1316541303
Name:EASTERN ISLAND DENTAL CARE PLLC
Entity Type:Organization
Organization Name:EASTERN ISLAND DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-413-2912
Mailing Address - Street 1:195 N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4005
Mailing Address - Country:US
Mailing Address - Phone:631-226-0146
Mailing Address - Fax:
Practice Address - Street 1:195 N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4005
Practice Address - Country:US
Practice Address - Phone:631-226-0146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03269418Medicaid