Provider Demographics
NPI:1790149045
Name:THREE VILLAGE ORTHODONTICS
Entity Type:Organization
Organization Name:THREE VILLAGE ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:EVERETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-689-3131
Mailing Address - Street 1:2500 NESCONSET HWY
Mailing Address - Street 2:BUILDING 6-B
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-689-3131
Mailing Address - Fax:631-689-3529
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BUILDING 6-B
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-689-3131
Practice Address - Fax:631-689-3529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0542941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00000000000000000000Medicaid