Healthcare Provider Details

I. General information

NPI: 1518047166
Provider Name (Legal Business Name): CAPITAL DISTRICT ORAL & MAXILLOFACIAL SURGEONS,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 SOUTHWOODS BLVD
ALBANY NY
12211-2526
US

IV. Provider business mailing address

7 SOUTHWOODS BLVD
ALBANY NY
12211-2526
US

V. Phone/Fax

Practice location:
  • Phone: 518-445-2505
  • Fax: 518-445-2508
Mailing address:
  • Phone: 518-445-2505
  • Fax: 518-445-2508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: PAT PANUCCI
Title or Position: PRACTICE MANAGER
Credential:
Phone: 518-445-2505