Healthcare Provider Details

I. General information

NPI: 1033343413
Provider Name (Legal Business Name): IDENT DENTAL AT FISHKILL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WESTAGE BUSINESS CTR DR SUITE 233
FISHKILL NY
12524-2264
US

IV. Provider business mailing address

200 WESTAGE BUSINESS CTR DR SUITE 233
FISHKILL NY
12524-2264
US

V. Phone/Fax

Practice location:
  • Phone: 914-245-4332
  • Fax:
Mailing address:
  • Phone: 888-433-6820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number048328
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number051732
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number049967
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ADAN SPOSATO
Title or Position: ADMINISTRATOR
Credential:
Phone: 888-433-6820