Healthcare Provider Details

I. General information

NPI: 1831293562
Provider Name (Legal Business Name): ANTONIO BONCORDO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 1/2 ALBANY SHAKER RD
LOUDONVILLE NY
12211
US

IV. Provider business mailing address

515 1/2 ALBANY SHAKER RD
LOUDONVILLE NY
12211
US

V. Phone/Fax

Practice location:
  • Phone: 518-458-1320
  • Fax: 518-458-9670
Mailing address:
  • Phone: 518-458-1320
  • Fax: 518-458-9670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0460501
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: