=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265593420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCELDENT OF ORANGE/SULLIVAN, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 03/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 127-131 EAST MAINT ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-342-5866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127-131 EAST MAINT ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-342-5866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL DIRECTOR
-----------------------------------------------------
Name | MS. BETTY ANN OGDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-342-5866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 50528
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------