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General NPI Number Information
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NPI Number | 1811121379
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Entity Type | Organization
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Legal Business Name | IDENT DENTAL AT MIDDLETOWN
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Dates
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Enumeration Date | 05/12/2009
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Last Update Date | 05/12/2009
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Provider Practice Location Address
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Address Line | 453 ROUTE 211 E SUITE 103
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City | MIDDLETOWN
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State | NY
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Zip | 10940-2206
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Country | US
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Telephone | 888-433-6820
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Fax |
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Provider Business Mailing Address
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Address Line | 453 ROUTE 211 E SUITE 103
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City | MIDDLETOWN
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State | NY
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Zip | 10940-2206
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Country | US
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Telephone | 888-433-6820
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ADAM SPOSATO
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Credential |
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Telephone | 914-245-4332
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | 048328
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 051732
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number | 049967
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License Number State | NY
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