Provider Demographics
NPI:1417158643
Name:SPIVAK, LAURA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:L
Last Name:SPIVAK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:35 CAUMSETT WOODS LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1245
Mailing Address - Country:US
Mailing Address - Phone:516-364-8372
Mailing Address - Fax:516-682-5744
Practice Address - Street 1:158 E MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2988
Practice Address - Country:US
Practice Address - Phone:631-385-1212
Practice Address - Fax:631-385-2400
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0434551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice