1548564289 NPI number — CAPITAL DISTRICT ENDODONTICS, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548564289 NPI number — CAPITAL DISTRICT ENDODONTICS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL DISTRICT ENDODONTICS, PC
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:
1548564289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2317 BALLTOWN RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
NISKAYUNA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12309-2339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-377-1234
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2317 BALLTOWN RD
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
NISKAYUNA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12309-2339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-377-1234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RIZZUTO
Authorized Official First Name:
BART
Authorized Official Middle Name:
Authorized Official Title or Position:
ENDODONTIST
Authorized Official Telephone Number:
518-377-1234

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  044203 , 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: 048904 . This is a "DDS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 044203 . This is a "DDS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".