Provider Demographics
NPI:1912338773
Name:BOHEMIA DENTAL ARTS
Entity Type:Organization
Organization Name:BOHEMIA DENTAL ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIMONE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-589-8585
Mailing Address - Street 1:1125 SMITHTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2160
Mailing Address - Country:US
Mailing Address - Phone:631-589-8585
Mailing Address - Fax:
Practice Address - Street 1:1125 SMITHTOWN AVE
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2160
Practice Address - Country:US
Practice Address - Phone:631-589-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-04
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05320411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty