Provider Demographics
NPI:1770705766
Name:STONY BROOK FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:STONY BROOK FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-751-7645
Mailing Address - Street 1:207 HALLOCK RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3033
Mailing Address - Country:US
Mailing Address - Phone:631-751-7645
Mailing Address - Fax:631-751-4170
Practice Address - Street 1:207 HALLOCK RD
Practice Address - Street 2:SUITE 5
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3033
Practice Address - Country:US
Practice Address - Phone:631-751-7645
Practice Address - Fax:631-751-4170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0474301223G0001X
NY0480621223X0400X
NY0467031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty