Provider Demographics
NPI:1720766868
Name:SOUTH FORK FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:SOUTH FORK FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:SHACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-324-7927
Mailing Address - Street 1:4 SCHEYER CT
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:426 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:EAST QUOGUE
Practice Address - State:NY
Practice Address - Zip Code:11942-3952
Practice Address - Country:US
Practice Address - Phone:631-653-4479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty