Provider Demographics
NPI:1003391855
Name:SENECA RIDGE DENTAL
Entity Type:Organization
Organization Name:SENECA RIDGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST, MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAPPUCCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-674-9444
Mailing Address - Street 1:3626 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3400
Mailing Address - Country:US
Mailing Address - Phone:716-674-9444
Mailing Address - Fax:
Practice Address - Street 1:3626 SENECA ST
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3400
Practice Address - Country:US
Practice Address - Phone:716-674-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03971042Medicaid
PA1029678060001Medicaid