Healthcare Provider Details

I. General information

NPI: 1164451035
Provider Name (Legal Business Name): FAMILY DENTAL ASSOCIATES LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 PARK AVE
MECHANICVILLE NY
12118
US

IV. Provider business mailing address

211 PARK AVE
MECHANICVILLE NY
12118
US

V. Phone/Fax

Practice location:
  • Phone: 518-664-0762
  • Fax: 518-664-0765
Mailing address:
  • Phone: 518-664-0762
  • Fax: 518-664-0765

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number0461981
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number046460
License Number StateNY

VIII. Authorized Official

Name: DR. PETRA VICTORIA ENZIEN
Title or Position: DENTIST PARTNER
Credential: DMD
Phone: 518-664-0762