Provider Demographics
NPI:1821228164
Name:STATEN ISLAND SMILES AT THE PAVILLION
Entity Type:Organization
Organization Name:STATEN ISLAND SMILES AT THE PAVILLION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:MORMINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-761-5600
Mailing Address - Street 1:1887 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3923
Mailing Address - Country:US
Mailing Address - Phone:718-761-5600
Mailing Address - Fax:718-761-7966
Practice Address - Street 1:1887 RICHMOND AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3923
Practice Address - Country:US
Practice Address - Phone:718-761-5600
Practice Address - Fax:718-761-7966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0424341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty