Provider Demographics
NPI:1326289695
Name:IDENTAL
Entity Type:Organization
Organization Name:IDENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-437-4380
Mailing Address - Street 1:2600 SOUTH RD
Mailing Address - Street 2:SUITE 21 A
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-7003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 SOUTH RD
Practice Address - Street 2:SUITE 21 A
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-7003
Practice Address - Country:US
Practice Address - Phone:845-437-4380
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty