Provider Demographics
NPI:1144608936
Name:SMITH HAVEN DENTISTRY, PLLC
Entity type:Organization
Organization Name:SMITH HAVEN DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-588-3636
Mailing Address - Street 1:2233 NESCONSET HWY
Mailing Address - Street 2:STE #101
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1000
Mailing Address - Country:US
Mailing Address - Phone:631-588-3636
Mailing Address - Fax:
Practice Address - Street 1:2233 NESCONSET HWY
Practice Address - Street 2:STE #101
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1000
Practice Address - Country:US
Practice Address - Phone:631-588-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-12
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental