Provider Demographics
NPI:1578841672
Name:HAMPTON PEDIATRIC DENTAL ASSOCIATES PC
Entity Type:Organization
Organization Name:HAMPTON PEDIATRIC DENTAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:COSENZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-287-8687
Mailing Address - Street 1:97 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-3300
Mailing Address - Country:US
Mailing Address - Phone:631-287-8687
Mailing Address - Fax:631-204-1430
Practice Address - Street 1:97 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-3300
Practice Address - Country:US
Practice Address - Phone:631-287-8687
Practice Address - Fax:631-204-1430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0433911223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01476553Medicaid