Provider Demographics
NPI:1942562376
Name:CONCERNED DENTAL CARE OF PORT JEFFERSON, PLLC
Entity Type:Organization
Organization Name:CONCERNED DENTAL CARE OF PORT JEFFERSON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENSTERSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-928-1018
Mailing Address - Street 1:492 OLD TOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-928-1018
Mailing Address - Fax:
Practice Address - Street 1:492 OLD TOWN ROAD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-928-1018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0320771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty