Provider Demographics
NPI:1639353345
Name:PM DENTAL SERVICES P.C.
Entity type:Organization
Organization Name:PM DENTAL SERVICES P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-748-6136
Mailing Address - Street 1:299 CANDLEWOOD PATH
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8003
Mailing Address - Country:US
Mailing Address - Phone:631-748-6136
Mailing Address - Fax:
Practice Address - Street 1:23520 147TH AVE
Practice Address - Street 2:SUITE# 3
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-3293
Practice Address - Country:US
Practice Address - Phone:718-723-4878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PMDENTAL SERVICES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0419741223G0001X
NY0371491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01109815Medicaid
NY00739359Medicaid