1679652747 NPI number — ASSOCIATED DENTAL ARTS, 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 1679652747 NPI number — ASSOCIATED DENTAL ARTS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASSOCIATED DENTAL ARTS, 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:
6
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:
1679652747
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 PINE WEST PLZ
Provider Second Line Business Mailing Address:
WASHINGTON AVENUE EXTENSION
Provider Business Mailing Address City Name:
ALBANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12205-5587
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-456-7673
Provider Business Mailing Address Fax Number:
518-456-8256

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5 PINE WEST PLZ
Provider Second Line Business Practice Location Address:
WASHINGTON AVENUE EXTENSION
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12205-5587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-456-7673
Provider Business Practice Location Address Fax Number:
518-456-8256
Provider Enumeration Date:
11/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SANTORO
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
ONOFRIO
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
518-690-4102

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  026279 , 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: 02197400 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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