=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831229418
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DECKER,SBUTTONI,BOGHOSIAN,DICERBO SPECIALISTS IN ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1004 WESTERN AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12203-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-489-8377
-----------------------------------------------------
Fax | 518-489-8462
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1004 WESTERN AVE
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12203-2743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-489-8377
-----------------------------------------------------
Fax | 518-489-8462
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. A. THOMAS DECKER
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 518-489-8377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 0299761
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------