MEDICARE: FAMILY DENTAL ASSOCIATES LLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0461981	NY
2	122300000X	Dentist	046460	NY

General Provider Information

NPI Number	:	1164451035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DENTAL ASSOCIATES LLP

Provider Business Mailing Address
First Line	:	211 PARK AVE
Second Line	:
City	:	MECHANICVILLE
State	:	NY
Zip	:	12118
Country	:	US
Telephone Number	:	518-664-0762
Fax Number	:	518-664-0765

Provider Business Practice Location Address
First Line	:	211 PARK AVE
Second Line	:
City	:	MECHANICVILLE
State	:	NY
Zip	:	12118
Country	:	US
Telephone Number	:	518-664-0762
Fax Number	:	518-664-0765

Authorized Official
Title or Position	:	DENTIST PARTNER
Name	:	DR. PETRA VICTORIA ENZIEN
Credential	:	DMD
Telephone Number	:	518-664-0762

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	08/22/2020

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