Provider Demographics
NPI:1679697429
Name:SOUTH ISLAND PERIODONTICS AND IMPLANTOLOGY PLLC
Entity Type:Organization
Organization Name:SOUTH ISLAND PERIODONTICS AND IMPLANTOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARKUS
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-295-9566
Mailing Address - Street 1:657 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516
Mailing Address - Country:US
Mailing Address - Phone:516-295-9566
Mailing Address - Fax:516-706-7061
Practice Address - Street 1:657 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:CEDARHURST
Practice Address - State:NY
Practice Address - Zip Code:11516
Practice Address - Country:US
Practice Address - Phone:516-295-9566
Practice Address - Fax:516-706-7061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0419141223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty