Provider Demographics
NPI:1700420429
Name:CHAVKIN ORAL AND MAXILLOFACIAL SURGERY LLC
Entity Type:Organization
Organization Name:CHAVKIN ORAL AND MAXILLOFACIAL SURGERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YANELIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-755-7960
Mailing Address - Street 1:414 JERICHO TPKE STE 2
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4510
Mailing Address - Country:US
Mailing Address - Phone:516-755-7960
Mailing Address - Fax:516-231-2136
Practice Address - Street 1:414 JERICHO TPKE STE 2
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4510
Practice Address - Country:US
Practice Address - Phone:516-755-7960
Practice Address - Fax:516-231-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1417354457OtherNPI
NY1093754467OtherNPI