Provider Demographics
NPI:1417087156
Name:LONG ISLAND ORTHODONTIC ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:LONG ISLAND ORTHODONTIC ASSOCIATES, P.C.
Other - Org Name:MARY BUATTI ROMEO DMD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BUATTI
Authorized Official - Last Name:ROMEO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-541-9396
Mailing Address - Street 1:100 CLARK AVE
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-4950
Mailing Address - Country:US
Mailing Address - Phone:516-541-9396
Mailing Address - Fax:516-541-9510
Practice Address - Street 1:100 CLARK AVE
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-4950
Practice Address - Country:US
Practice Address - Phone:516-541-9396
Practice Address - Fax:516-541-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0379431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty