Provider Demographics
NPI:1699055285
Name:ADVANCED IMPLANT AND ORAL SURGERY P.C.
Entity type:Organization
Organization Name:ADVANCED IMPLANT AND ORAL SURGERY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YURIY
Authorized Official - Middle Name:
Authorized Official - Last Name:YUSUPOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-923-1101
Mailing Address - Street 1:17 WALT WHITMAN RD STE 3
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-3610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 WALT WHITMAN RD STE 3
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-3610
Practice Address - Country:US
Practice Address - Phone:631-923-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052623261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery