Provider Demographics
NPI:1275823734
Name:EMBLEMHEALTH MEDICAL AND DENTAL SERVICES INC.
Entity Type:Organization
Organization Name:EMBLEMHEALTH MEDICAL AND DENTAL SERVICES INC.
Other - Org Name:GHI FAMILY DENTAL PRACTICE/OEHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-869-1717
Mailing Address - Street 1:1873 WESTERN AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-5028
Mailing Address - Country:US
Mailing Address - Phone:518-869-1044
Mailing Address - Fax:518-869-1965
Practice Address - Street 1:1873 WESTERN AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-5028
Practice Address - Country:US
Practice Address - Phone:518-869-1044
Practice Address - Fax:518-869-1965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-18
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0101222R261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0101222ROtherFACILITY LICENSE