Provider Demographics
NPI:1336631035
Name:MICHAEL Y IVRY DDS PC
Entity type:Organization
Organization Name:MICHAEL Y IVRY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:YEHUDA
Authorized Official - Last Name:IVRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-252-2076
Mailing Address - Street 1:499 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1538
Mailing Address - Country:US
Mailing Address - Phone:631-252-2076
Mailing Address - Fax:516-596-7455
Practice Address - Street 1:2550 SEAGIRT BLVD
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691
Practice Address - Country:US
Practice Address - Phone:718-327-2147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047962204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1154509503Medicaid