Provider Demographics
NPI:1366613317
Name:STATION DENTAL ASSOCIATES INC.
Entity type:Organization
Organization Name:STATION DENTAL ASSOCIATES INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHELDON
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:MILO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:516-448-4652
Mailing Address - Street 1:177 OLD COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2102
Mailing Address - Country:US
Mailing Address - Phone:631-208-3068
Mailing Address - Fax:631-208-3137
Practice Address - Street 1:177 OLD COUNTRY RD
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2102
Practice Address - Country:US
Practice Address - Phone:631-208-3068
Practice Address - Fax:631-208-3137
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATION DENTAL ASSOCIATES INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-18
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0454551223G0001X
NY0396101223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02672402Medicaid