Provider Demographics
NPI:1699168757
Name:DENTISTRY UNLIMITED OF ST. JAMES PLLC
Entity type:Organization
Organization Name:DENTISTRY UNLIMITED OF ST. JAMES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LAGUARDIA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:631-360-1544
Mailing Address - Street 1:872 MIDDLE COUNTRY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-3223
Mailing Address - Country:US
Mailing Address - Phone:631-360-1544
Mailing Address - Fax:631-360-1839
Practice Address - Street 1:872 MIDDLE COUNTRY RD STE 4
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-3223
Practice Address - Country:US
Practice Address - Phone:631-360-1544
Practice Address - Fax:631-360-1839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-13
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048499261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02701788Medicaid