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General NPI Number Information
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NPI Number | 1356876460
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Entity Type | Organization
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Legal Business Name | MADISON DENTAL MANAGEMENT ASSOCIATES LLC
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Dates
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Enumeration Date | 04/26/2017
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Last Update Date | 04/26/2017
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Provider Practice Location Address
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Address Line | 1579 BRENTWOOD RD
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City | BAY SHORE
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State | NY
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Zip | 11706-3225
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Country | US
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Telephone | 631-665-8484
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Fax | 631-665-3953
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Provider Business Mailing Address
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Address Line | 1579 BRENTWOOD RD
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City | BAY SHORE
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State | NY
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Zip | 11706-3225
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Country | US
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Telephone | 631-665-8484
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Fax | 631-665-3953
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. EUGENE LOUIS ANTENUCCI
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Credential | DDS
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Telephone | 631-665-8484
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 038340-1
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License Number State | NY
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