Provider Demographics
NPI:1659587970
Name:GENCO, PETER A (GENERAL DENTIST DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:A
Last Name:GENCO
Suffix:
Gender:M
Credentials:GENERAL DENTIST DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH FALLSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12779
Mailing Address - Country:US
Mailing Address - Phone:845-434-1202
Mailing Address - Fax:845-434-2878
Practice Address - Street 1:5203 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SOUTH FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12779
Practice Address - Country:US
Practice Address - Phone:845-434-1202
Practice Address - Fax:845-434-2878
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04993711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice