Healthcare Provider Details

I. General information

NPI: 1700969565
Provider Name (Legal Business Name): PRISCILLA ALDEN KONECKY D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 5TH AVE SUITE 1863
NEW YORK NY
10111-0100
US

IV. Provider business mailing address

630 5TH AVE SUITE 1863
NEW YORK NY
10111-0100
US

V. Phone/Fax

Practice location:
  • Phone: 212-969-9690
  • Fax: 212-489-3907
Mailing address:
  • Phone: 212-969-9690
  • Fax: 212-489-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number33646
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: