1053590646 NPI number — DR. EUGENE MICHAEL TEDALDI SR. DDS

Table of content: DR. EUGENE MICHAEL TEDALDI SR. DDS (NPI 1053590646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053590646 NPI number — DR. EUGENE MICHAEL TEDALDI SR. DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEDALDI
Provider First Name:
EUGENE
Provider Middle Name:
MICHAEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TEDALDI
Provider Other First Name:
EUGENE
Provider Other Middle Name:
MICHAEL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
SR.
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1053590646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 378
Provider Second Line Business Mailing Address:
SUITE 5
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-234-7462
Provider Business Mailing Address Fax Number:
914-763-5544

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MAIN STREET 26-28 VILLAGE GREEN
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-234-7462
Provider Business Practice Location Address Fax Number:
914-763-5544
Provider Enumeration Date:
10/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  020483 , 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)





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