1114080041 NPI number — ROME FAMILY DENTAL SERVICE P.C.

Table of content: (NPI 1114080041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114080041 NPI number — ROME FAMILY DENTAL SERVICE P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROME FAMILY DENTAL SERVICE P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114080041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 NORTH WASHINGTON ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROME
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-339-5830
Provider Business Mailing Address Fax Number:
315-337-8409

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 NORTH WASHINGTON ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROME
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-339-5830
Provider Business Practice Location Address Fax Number:
315-337-8409
Provider Enumeration Date:
12/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALLINI
Authorized Official First Name:
ALBINO
Authorized Official Middle Name:
NICHOLAS
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
315-339-5830

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  044155 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 030067 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01382856 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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