Healthcare Provider Details

I. General information

NPI: 1952558074
Provider Name (Legal Business Name): COUNTRYSIDE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 KINDERHOOK ST
CHATHAM NY
12037-1207
US

IV. Provider business mailing address

42 KINDERHOOK ST
CHATHAM NY
12037-1207
US

V. Phone/Fax

Practice location:
  • Phone: 518-392-5231
  • Fax: 518-392-7339
Mailing address:
  • Phone: 518-392-5231
  • Fax: 518-392-7339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number039271
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number045941
License Number StateNY

VIII. Authorized Official

Name: DR. DOMENIC RICCOBONO
Title or Position: OWNER
Credential: DDS
Phone: 518-392-5231