1306973177 NPI number — DR. MARK GEORGE CIOVACCO DMD

Table of content: SUZANNE DOSER KNIGHT LPT (NPI 1346416054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306973177 NPI number — DR. MARK GEORGE CIOVACCO DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CIOVACCO
Provider First Name:
MARK
Provider Middle Name:
GEORGE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
M

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:
1306973177
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 REDONDO DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POUGHKEEPSIE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-473-5049
Provider Business Mailing Address Fax Number:
845-471-3955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 REDONDO DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POUGHKEEPSIE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-473-5049
Provider Business Practice Location Address Fax Number:
845-471-3955
Provider Enumeration Date:
02/27/2007

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: 1223G0001X , with the licence number:  034089 , 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: 00569936 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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