Provider Demographics
NPI:1114080041
Name:ROME FAMILY DENTAL SERVICE P.C.
Entity Type:Organization
Organization Name:ROME FAMILY DENTAL SERVICE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALBINO
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:BALLINI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-339-5830
Mailing Address - Street 1:215 NORTH WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440
Mailing Address - Country:US
Mailing Address - Phone:315-339-5830
Mailing Address - Fax:315-337-8409
Practice Address - Street 1:215 NORTH WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440
Practice Address - Country:US
Practice Address - Phone:315-339-5830
Practice Address - Fax:315-337-8409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044155122300000X
NY0300671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01382856Medicaid