Healthcare Provider Details

I. General information

NPI: 1326183120
Provider Name (Legal Business Name): MARK J POLSINELLO D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 ALBANY SHAKER RD SUITE 201
LOUDONVILLE NY
12211-1961
US

IV. Provider business mailing address

399 ALBANY SHAKER RD SUITE 201
LOUDONVILLE NY
12211-1961
US

V. Phone/Fax

Practice location:
  • Phone: 518-438-1131
  • Fax: 518-438-9490
Mailing address:
  • Phone: 518-438-1131
  • Fax: 518-438-9490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number045465
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: