Provider Demographics
NPI:1861664864
Name:PM DENTAL SERVICES PC
Entity type:Organization
Organization Name:PM DENTAL SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-748-6136
Mailing Address - Street 1:299 CANDLEWOOD PATH
Mailing Address - Street 2:
Mailing Address - City:DIX HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11746-8003
Mailing Address - Country:US
Mailing Address - Phone:631-748-6136
Mailing Address - Fax:
Practice Address - Street 1:9045 PITKIN AVE
Practice Address - Street 2:
Practice Address - City:OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11417-2706
Practice Address - Country:US
Practice Address - Phone:718-843-7551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041974122300000X
NY037149122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01109815Medicaid
NY00739359Medicaid