Provider Demographics
NPI:1013319508
Name:PORT WASHINGTON DENTAL
Entity Type:Organization
Organization Name:PORT WASHINGTON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SULTAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SALEM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-883-1234
Mailing Address - Street 1:27 S BAYLES AVE
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-3708
Mailing Address - Country:US
Mailing Address - Phone:516-883-1234
Mailing Address - Fax:516-883-1357
Practice Address - Street 1:27 S BAYLES AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-3708
Practice Address - Country:US
Practice Address - Phone:516-883-1234
Practice Address - Fax:516-883-1357
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:S S SALEM DDS,PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty