Provider Demographics
NPI:1497289037
Name:STONY BROOK ORAL AND FACIAL SURGERY PC
Entity Type:Organization
Organization Name:STONY BROOK ORAL AND FACIAL SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PROOTHI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:631-675-9601
Mailing Address - Street 1:207 HALLOCK RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3033
Mailing Address - Country:US
Mailing Address - Phone:631-675-9601
Mailing Address - Fax:631-675-9602
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 2
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-675-9601
Practice Address - Fax:631-675-9602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051735-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty