Provider Demographics
NPI:1992972012
Name:ISLAND SMILE DENTAL GROUP
Entity type:Organization
Organization Name:ISLAND SMILE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.D.S
Authorized Official - Prefix:DR
Authorized Official - First Name:SULTAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-520-5858
Mailing Address - Street 1:3072 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-1344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3072 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-1344
Practice Address - Country:US
Practice Address - Phone:516-520-5858
Practice Address - Fax:516-520-6938
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ISLAND SMILE DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049840305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization