Provider Demographics
NPI:1508195975
Name:RODNEY RASTEGAR DDS PLLC
Entity Type:Organization
Organization Name:RODNEY RASTEGAR DDS PLLC
Other - Org Name:PROGRESSIVE ORAL SURGERY OF LONG ISLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:DAVILA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-741-4415
Mailing Address - Street 1:23 BOND STREET
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021
Mailing Address - Country:US
Mailing Address - Phone:516-482-0329
Mailing Address - Fax:516-482-0401
Practice Address - Street 1:601 FRANKLIN AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530
Practice Address - Country:US
Practice Address - Phone:516-741-4415
Practice Address - Fax:516-741-4417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0486921223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty