=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689020679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYBROOK DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2016
-----------------------------------------------------
Last Update Date | 05/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 WILLOWBROOK RD
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-5864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-792-5103
-----------------------------------------------------
Fax | 518-792-5110
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 WILLOWBROOK RD
-----------------------------------------------------
City | QUEENSBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12804-5864
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-792-5103
-----------------------------------------------------
Fax | 518-792-5110
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GINA MARIE CANALE
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 518-792-5103
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 044937
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------