Provider Demographics
NPI:1407190333
Name:MONROE DENTAL GROUP, LLC
Entity Type:Organization
Organization Name:MONROE DENTAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:845-782-5040
Mailing Address - Street 1:809 STATE ROUTE 208
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1829
Mailing Address - Country:US
Mailing Address - Phone:845-782-5040
Mailing Address - Fax:845-782-3478
Practice Address - Street 1:809 STATE ROUTE 208
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-1829
Practice Address - Country:US
Practice Address - Phone:845-782-5040
Practice Address - Fax:845-782-3478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY55718122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3399442Medicaid