MEDICARE: DR. MICHAEL JOHN GENCO DDS

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	122300000X	Dentist	039963	NY

General Provider Information

NPI Number	:	1871797878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JOHN GENCO DDS

Provider Business Mailing Address
First Line	:	2155 82ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-2547
Country	:	US
Telephone Number	:	718-232-4155
Fax Number	:	718-232-3804

Provider Business Practice Location Address
First Line	:	2155 82ND ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11214-2547
Country	:	US
Telephone Number	:	718-232-4155
Fax Number	:	718-232-3804

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

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	07/08/2007

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