Provider Demographics
NPI:1750915377
Name:WADING RIVER PEDIATRIC DENTISTRY, PC
Entity type:Organization
Organization Name:WADING RIVER PEDIATRIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPISI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-524-6756
Mailing Address - Street 1:6336 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792-2030
Mailing Address - Country:US
Mailing Address - Phone:516-524-6756
Mailing Address - Fax:
Practice Address - Street 1:6336 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792-2030
Practice Address - Country:US
Practice Address - Phone:516-524-6756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty