Provider Demographics
NPI:1912013962
Name:PROFERA, LOUIS S (DDS)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:S
Last Name:PROFERA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 MONTAUK HWY
Mailing Address - Street 2:SUITE E
Mailing Address - City:EAST HAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11937
Mailing Address - Country:US
Mailing Address - Phone:631-324-5662
Mailing Address - Fax:631-324-5835
Practice Address - Street 1:65 MONTAUK HWY
Practice Address - Street 2:SUITE E
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937
Practice Address - Country:US
Practice Address - Phone:631-324-5662
Practice Address - Fax:631-324-5835
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0441511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice