Provider Demographics
NPI:1720328115
Name:STAR DENTAL CARE II PC
Entity Type:Organization
Organization Name:STAR DENTAL CARE II PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEFALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARCHAWALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-473-1338
Mailing Address - Street 1:1528 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2236
Mailing Address - Country:US
Mailing Address - Phone:631-473-1338
Mailing Address - Fax:631-473-1390
Practice Address - Street 1:1528 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11777-2236
Practice Address - Country:US
Practice Address - Phone:631-473-1338
Practice Address - Fax:631-473-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047506-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01869305Medicaid