Provider Demographics
NPI:1689020679
Name:BAYBROOK DENTAL GROUP
Entity Type:Organization
Organization Name:BAYBROOK DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CANALE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:518-792-5103
Mailing Address - Street 1:31 WILLOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-5864
Mailing Address - Country:US
Mailing Address - Phone:518-792-5103
Mailing Address - Fax:518-792-5110
Practice Address - Street 1:31 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-5864
Practice Address - Country:US
Practice Address - Phone:518-792-5103
Practice Address - Fax:518-792-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044937122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty