Healthcare Provider Details

I. General information

NPI: 1891761318
Provider Name (Legal Business Name): PINE STREET DENTAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 PINE ST SUITE 210
KINGSTON NY
12401-4947
US

IV. Provider business mailing address

138 PINE ST SUITE 210
KINGSTON NY
12401-4947
US

V. Phone/Fax

Practice location:
  • Phone: 845-338-6900
  • Fax: 845-338-6013
Mailing address:
  • Phone: 845-338-6900
  • Fax: 845-338-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0526781
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number029231
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number032380
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number040046
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0487491
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number038724
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number044009
License Number StateNY

VIII. Authorized Official

Name: DR. CHARLES MATTHEW FLIEGLER
Title or Position: DENTIST, OWNER
Credential: D.D.S.
Phone: 845-338-6900