Provider Demographics
NPI:1992889695
Name:SOUTH SHORE ORAL SURGERY ASSOC PC
Entity type:Organization
Organization Name:SOUTH SHORE ORAL SURGERY ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:A
Authorized Official - Last Name:VANNESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-766-0580
Mailing Address - Street 1:24 MAPLE AVE
Mailing Address - Street 2:SOUTH SHORE ORAL SURGERY ASSOC PC SUITE 6
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570
Mailing Address - Country:US
Mailing Address - Phone:516-766-0580
Mailing Address - Fax:516-766-6755
Practice Address - Street 1:24 MAPLE AVE
Practice Address - Street 2:SOUTH SHORE ORAL SURGERY ASSOC PC SUITE 6
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570
Practice Address - Country:US
Practice Address - Phone:516-766-0580
Practice Address - Fax:516-766-6755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty