Healthcare Provider Details

I. General information

NPI: 1457729337
Provider Name (Legal Business Name): RENAISSANCE DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2015
Last Update Date: 09/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 NORMANSKILL BLVD
DELMAR NY
12054-1335
US

IV. Provider business mailing address

4 NORMANSKILL BLVD
DELMAR NY
12054-1335
US

V. Phone/Fax

Practice location:
  • Phone: 518-261-4800
  • Fax:
Mailing address:
  • Phone: 518-261-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number052174
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number052174
License Number StateNY

VIII. Authorized Official

Name: DR. MARINA SHRAGA
Title or Position: PRESIDENT
Credential: DDS
Phone: 518-261-4800