Provider Demographics
NPI:1720160690
Name:KIRSHENBAUM PERUSO KAUTMAN LLP
Entity Type:Organization
Organization Name:KIRSHENBAUM PERUSO KAUTMAN LLP
Other - Org Name:CARLETON AVE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PERUSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-348-2500
Mailing Address - Street 1:109 CARLETON AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722
Mailing Address - Country:US
Mailing Address - Phone:631-348-2500
Mailing Address - Fax:631-234-4324
Practice Address - Street 1:109 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722
Practice Address - Country:US
Practice Address - Phone:631-348-2500
Practice Address - Fax:631-234-4324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01808433Medicaid