Healthcare Provider Details

I. General information

NPI: 1982694097
Provider Name (Legal Business Name): MICHAEL KENT DELUKE D.D.S, M.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2317 BALLTOWN RD #101
NISKAYUNA NY
12309-2339
US

IV. Provider business mailing address

29 BANCKER AVE
SCOTIA NY
12302-3103
US

V. Phone/Fax

Practice location:
  • Phone: 518-377-2700
  • Fax: 518-831-9005
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number050161-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: