Healthcare Provider Details

I. General information

NPI: 1659587970
Provider Name (Legal Business Name): PETER A GENCO GENERAL DENTIST DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5203 MAIN STREET
SOUTH FALLSBURG NY
12779
US

IV. Provider business mailing address

5203 MAIN STREET
SOUTH FALLSBURG NY
12779
US

V. Phone/Fax

Practice location:
  • Phone: 845-434-1202
  • Fax: 845-434-2878
Mailing address:
  • Phone: 845-434-1202
  • Fax: 845-434-2878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0499371
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: