Provider Demographics
NPI:1801896667
Name:LONG ISLAND ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES LLP
Entity type:Organization
Organization Name:LONG ISLAND ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CAPUANO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-696-9752
Mailing Address - Street 1:132 TERRYVILLE RD
Mailing Address - Street 2:P.O. BOX 222
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1372
Mailing Address - Country:US
Mailing Address - Phone:631-473-6400
Mailing Address - Fax:631-473-7297
Practice Address - Street 1:132 TERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1372
Practice Address - Country:US
Practice Address - Phone:631-473-6400
Practice Address - Fax:631-473-7297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA100027760OtherPTAN