MEDICARE: DR. PRISCILLA ALDEN KONECKY D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	33646	NY

General Provider Information

NPI Number	:	1700969565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRISCILLA ALDEN KONECKY D.D.S.

Provider Business Mailing Address
First Line	:	630 5TH AVE
Second Line	:	SUITE 1863
City	:	NEW YORK
State	:	NY
Zip	:	10111-0100
Country	:	US
Telephone Number	:	212-969-9690
Fax Number	:	212-489-3907

Provider Business Practice Location Address
First Line	:	630 5TH AVE
Second Line	:	SUITE 1863
City	:	NEW YORK
State	:	NY
Zip	:	10111-0100
Country	:	US
Telephone Number	:	212-969-9690
Fax Number	:	212-489-3907

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	07/08/2007

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