Provider Demographics
NPI:1528189495
Name:THOMAS J. DEGENERO D.D.S.
Entity Type:Organization
Organization Name:THOMAS J. DEGENERO D.D.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEGENERO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-674-8500
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 RTE 150
Practice Address - Street 2:
Practice Address - City:WEST SAND LAKE
Practice Address - State:NY
Practice Address - Zip Code:12196
Practice Address - Country:US
Practice Address - Phone:518-674-8500
Practice Address - Fax:518-674-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037900-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty