MEDICARE: SPRINGVALLEYDENTALCAREPC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1255619458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRINGVALLEYDENTALCAREPC

Provider Business Mailing Address
First Line	:	37 KENNEDY DR
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-5319
Country	:	US
Telephone Number	:	845-352-0714
Fax Number	:	845-352-1439

Provider Business Practice Location Address
First Line	:	37 KENNEDY DR
Second Line	:
City	:	SPRING VALLEY
State	:	NY
Zip	:	10977-5319
Country	:	US
Telephone Number	:	845-352-0714
Fax Number	:	845-352-1439

Authorized Official
Title or Position	:	OWNER
Name	:	CARLOS J DULUC
Credential	:
Telephone Number	:	845-352-0714

Provider Enumeration Date	:	07/22/2011
Last Update Date	:	09/09/2011

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