Healthcare Provider Details

I. General information

NPI: 1306923032
Provider Name (Legal Business Name): DOMINIC A EMANUELE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69 OLD TEMPLE HILL RD
VAILS GATE NY
12584
US

IV. Provider business mailing address

PO BOX 539 69 OLD TEMPLE HILL RD
VAILS GATE NY
12584-0539
US

V. Phone/Fax

Practice location:
  • Phone: 845-562-2063
  • Fax: 845-562-4194
Mailing address:
  • Phone: 845-562-2063
  • Fax: 845-562-4194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number042760
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: