Provider Demographics
NPI:1346671872
Name:DEGENERO, THOMAS I
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DEGENERO
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:WEST SAND LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12196-0367
Mailing Address - Country:US
Mailing Address - Phone:518-674-8500
Mailing Address - Fax:518-674-8885
Practice Address - Street 1:4482 NY ROUTE 150
Practice Address - Street 2:
Practice Address - City:WEST SAND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12018
Practice Address - Country:US
Practice Address - Phone:518-674-8500
Practice Address - Fax:518-674-8885
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY37900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist