=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588104376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PINE BUSH DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2412 ROUTE 52
-----------------------------------------------------
City | PINE BUSH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12566-7037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-744-5422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 STATE ROUTE 208
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10950-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-782-5040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DDS
-----------------------------------------------------
Name | MARC FABER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-744-5422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 055718
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------