Provider Demographics
NPI:1851793707
Name:LONG ISLAND DENTAL IMPLANT ASSOCIATES
Entity Type:Organization
Organization Name:LONG ISLAND DENTAL IMPLANT ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIOT
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSCHITZKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-744-5700
Mailing Address - Street 1:31 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9433
Mailing Address - Country:US
Mailing Address - Phone:631-744-5700
Mailing Address - Fax:
Practice Address - Street 1:31 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-9433
Practice Address - Country:US
Practice Address - Phone:631-744-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty