Provider Demographics
NPI:1467610618
Name:ANTOS, EDWARD W JR (DDS)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:W
Last Name:ANTOS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RTE 25A
Mailing Address - Street 2:
Mailing Address - City:E SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733
Mailing Address - Country:US
Mailing Address - Phone:631-941-4435
Mailing Address - Fax:631-941-4717
Practice Address - Street 1:45 RTE 25A
Practice Address - Street 2:
Practice Address - City:E SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-941-4435
Practice Address - Fax:631-941-4717
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0213611223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU62846Medicare UPIN