Provider Demographics
NPI:1013184605
Name:WISDOM TOOTH OF LINDENHURST
Entity Type:Organization
Organization Name:WISDOM TOOTH OF LINDENHURST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:H
Authorized Official - Last Name:KANTROWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-225-1900
Mailing Address - Street 1:600D N WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757
Mailing Address - Country:US
Mailing Address - Phone:631-225-1900
Mailing Address - Fax:631-225-1904
Practice Address - Street 1:600D N WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757
Practice Address - Country:US
Practice Address - Phone:631-225-1900
Practice Address - Fax:631-225-1904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035654122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00632820Medicaid