Healthcare Provider Details

I. General information

NPI: 1528189495
Provider Name (Legal Business Name): THOMAS J. DEGENERO D.D.S.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4482 NY RTE 150
WEST SAND LAKE NY
12196
US

IV. Provider business mailing address

PO BOX 367
WEST SAND LAKE NY
12196-0367
US

V. Phone/Fax

Practice location:
  • Phone: 518-674-8500
  • Fax: 518-674-8885
Mailing address:
  • Phone: 518-674-8500
  • Fax: 518-674-8885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number037900-1
License Number StateNY

VIII. Authorized Official

Name: DR. THOMAS J DEGENERO
Title or Position: OWNER
Credential: DDS
Phone: 518-674-8500