Provider Demographics
NPI:1598136145
Name:PATCHOGUE ORTHODONTICS, PC
Entity Type:Organization
Organization Name:PATCHOGUE ORTHODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-447-7623
Mailing Address - Street 1:240 PATCHOGUE YAPHANK RD
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-4868
Mailing Address - Country:US
Mailing Address - Phone:631-447-7623
Mailing Address - Fax:631-289-3363
Practice Address - Street 1:240 PATCHOGUE YAPHANK RD
Practice Address - Street 2:
Practice Address - City:EAST PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4868
Practice Address - Country:US
Practice Address - Phone:631-447-7623
Practice Address - Fax:631-289-3363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY38848-1261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01067647Medicaid