Provider Demographics
NPI:1710060223
Name:LONG ISLAND ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:LONG ISLAND ORAL & MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCQUILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-294-9696
Mailing Address - Street 1:14 VANDERVENTER AVE
Mailing Address - Street 2:STE 260
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3737
Mailing Address - Country:US
Mailing Address - Phone:516-944-8330
Mailing Address - Fax:516-883-1598
Practice Address - Street 1:14 VANDERVENTER AVE
Practice Address - Street 2:STE 260
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3737
Practice Address - Country:US
Practice Address - Phone:516-944-8330
Practice Address - Fax:516-883-1598
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONG ISLAND ORAL & MAXILLOFACIAL SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD0W062Medicare PIN