Provider Demographics
NPI:1164451035
Name:FAMILY DENTAL ASSOCIATES LLP
Entity Type:Organization
Organization Name:FAMILY DENTAL ASSOCIATES LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETRA
Authorized Official - Middle Name:VICTORIA
Authorized Official - Last Name:ENZIEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:518-664-0762
Mailing Address - Street 1:211 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MECHANICVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12118
Mailing Address - Country:US
Mailing Address - Phone:518-664-0762
Mailing Address - Fax:518-664-0765
Practice Address - Street 1:211 PARK AVE
Practice Address - Street 2:
Practice Address - City:MECHANICVILLE
Practice Address - State:NY
Practice Address - Zip Code:12118
Practice Address - Country:US
Practice Address - Phone:518-664-0762
Practice Address - Fax:518-664-0765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046460122300000X
NY0461981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty