Healthcare Provider Details

I. General information

NPI: 1699205369
Provider Name (Legal Business Name): RICHARD GENCO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 MAIN ST
SOUTH FALLSBURG NY
12779-5422
US

IV. Provider business mailing address

5203 MAIN ST
SOUTH FALLSBURG NY
12779-5422
US

V. Phone/Fax

Practice location:
  • Phone: 845-434-1202
  • Fax:
Mailing address:
  • Phone: 845-434-1202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number044387-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number044387-1
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: