MEDICARE: ABDENTISTRYPLLC

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	046050-1	NY

General Provider Information

NPI Number	:	1265815088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABDENTISTRYPLLC

Provider Business Mailing Address
First Line	:	515 1/2 ALBANY SHAKER RD
Second Line	:
City	:	LOUDONVILLE
State	:	NY
Zip	:	12211-2135
Country	:	US
Telephone Number	:	518-458-1320
Fax Number	:	518-458-9670

Provider Business Practice Location Address
First Line	:	515 1/2 ALBANY SHAKER RD
Second Line	:
City	:	LOUDONVILLE
State	:	NY
Zip	:	12211-2135
Country	:	US
Telephone Number	:	518-458-1320
Fax Number	:	518-458-9670

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. ANTONIO BONCORDO
Credential	:	DMD
Telephone Number	:	518-458-1320

Provider Enumeration Date	:	06/30/2015
Last Update Date	:	06/30/2015

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