Provider Demographics
NPI:1598997900
Name:SUFFOLK PEDIATRIC DENTISTRY
Entity type:Organization
Organization Name:SUFFOLK PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SERINO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-928-8585
Mailing Address - Street 1:8 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1601
Mailing Address - Country:US
Mailing Address - Phone:631-928-8585
Mailing Address - Fax:631-928-8861
Practice Address - Street 1:8 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1601
Practice Address - Country:US
Practice Address - Phone:631-928-8585
Practice Address - Fax:631-928-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01864713Medicaid