Provider Demographics
NPI:1932489192
Name:HARBORBAY DENTAL
Entity Type:Organization
Organization Name:HARBORBAY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GRANDILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-666-0427
Mailing Address - Street 1:160 BRENTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-6948
Mailing Address - Country:US
Mailing Address - Phone:631-666-0427
Mailing Address - Fax:631-647-7687
Practice Address - Street 1:160 BRENTWOOD RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6948
Practice Address - Country:US
Practice Address - Phone:631-666-0427
Practice Address - Fax:631-647-7687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048345-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02699012Medicaid