=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790915726
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANTONY DESANTIS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2009
-----------------------------------------------------
Last Update Date | 12/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1092 MADISON AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12208-2248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-525-1757
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 73 TROY RD 1D
-----------------------------------------------------
City | EAST GREENBUSH
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12061-1334
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-451-9770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 054426
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------