Provider Demographics
NPI:1033541552
Name:IDENT DENTAL AT SUFFERN
Entity Type:Organization
Organization Name:IDENT DENTAL AT SUFFERN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:FERTUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-245-7977
Mailing Address - Street 1:200 WESTAGE BUSINESS CTR DR
Mailing Address - Street 2:SUITE 233
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-2264
Mailing Address - Country:US
Mailing Address - Phone:845-897-2097
Mailing Address - Fax:
Practice Address - Street 1:156 ROUTE 59
Practice Address - Street 2:SUITE A1
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-5005
Practice Address - Country:US
Practice Address - Phone:845-356-8844
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0472221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty