Provider Demographics
NPI:1588782650
Name:AIDS DENTAL SERVICES
Entity type:Organization
Organization Name:AIDS DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF IT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MANFREDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-733-7003
Mailing Address - Street 1:333 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-1231
Mailing Address - Country:US
Mailing Address - Phone:516-623-4420
Mailing Address - Fax:
Practice Address - Street 1:333 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-1231
Practice Address - Country:US
Practice Address - Phone:516-623-4420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01635336Medicaid