=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417115254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS DENTAL MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2008
-----------------------------------------------------
Last Update Date | 05/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 436 NEW SCOTLAND AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12208-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-857-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 436 NEW SCOTLAND AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12208-2710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-857-1876
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KARL F POGGE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-622-6288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------