1891761318 NPI number — PINE STREET DENTAL ASSOCIATES, P.C.

Table of content: (NPI 1891761318)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891761318 NPI number — PINE STREET DENTAL ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE STREET DENTAL ASSOCIATES, 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:
1891761318
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
138 PINE ST
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12401-4947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-338-6900
Provider Business Mailing Address Fax Number:
845-338-6013

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
138 PINE ST
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12401-4947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-338-6900
Provider Business Practice Location Address Fax Number:
845-338-6013
Provider Enumeration Date:
02/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FLIEGLER
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
MATTHEW
Authorized Official Title or Position:
DENTIST, OWNER
Authorized Official Telephone Number:
845-338-6900

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  0526781 , 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: 029231 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 032380 , 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: 040046 , 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: 0487491 , 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: 038724 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 044009 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0487491 . This is a "NYS DENTAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040046 . This is a "NYS DENTAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 029231 . This is a "NYS DENTAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 044009 . This is a "NYS DENTAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0526781 . This is a "NYS DENTAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 032380 . This is a "NYS DENTAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 038724 . This is a "NYS DENTAL LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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