Provider Demographics
NPI:1407843667
Name:MARCINISZYN, THADDEUS JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:JOSEPH
Last Name:MARCINISZYN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 GUY PARK AVE
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-3254
Mailing Address - Country:US
Mailing Address - Phone:518-842-3220
Mailing Address - Fax:518-843-0830
Practice Address - Street 1:191 GUY PARK AVE
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-3254
Practice Address - Country:US
Practice Address - Phone:518-842-3220
Practice Address - Fax:518-843-0830
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0304801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice