Provider Demographics
NPI:1619249059
Name:NORTH SHORE ORAL SURGERY, LLC
Entity Type:Organization
Organization Name:NORTH SHORE ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTAZEM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-265-9700
Mailing Address - Street 1:285 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE #108
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2978
Mailing Address - Country:US
Mailing Address - Phone:631-265-9700
Mailing Address - Fax:631-265-9703
Practice Address - Street 1:285 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE #108
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2978
Practice Address - Country:US
Practice Address - Phone:631-265-9700
Practice Address - Fax:631-265-9703
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0427301223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY521422POtherHIP
NY0565561OtherGHI MEDICAL
NY1364282OtherUNITED HEALTHCARE
NYD99121OtherEMPIRE BCBS
NYP3492579OtherOXFORD
NY116561OtherCIGNA DMO