Provider Demographics
NPI:1518139450
Name:NORMAN GROSS DDS BARRY WILDER DDS PC
Entity type:Organization
Organization Name:NORMAN GROSS DDS BARRY WILDER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAMILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SPINELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-732-0233
Mailing Address - Street 1:805 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-2504
Mailing Address - Country:US
Mailing Address - Phone:631-732-0233
Mailing Address - Fax:631-732-0247
Practice Address - Street 1:805 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-2504
Practice Address - Country:US
Practice Address - Phone:631-732-0233
Practice Address - Fax:631-732-0247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00652759Medicaid
NY00652584Medicaid