Provider Demographics
NPI:1891761318
Name:PINE STREET DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:PINE STREET DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:FLIEGLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:845-338-6900
Mailing Address - Street 1:138 PINE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-4947
Mailing Address - Country:US
Mailing Address - Phone:845-338-6900
Mailing Address - Fax:845-338-6013
Practice Address - Street 1:138 PINE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-4947
Practice Address - Country:US
Practice Address - Phone:845-338-6900
Practice Address - Fax:845-338-6013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0526781122300000X
NY0292311223G0001X
NY0323801223G0001X
NY0400461223G0001X
NY04874911223G0001X
NY0387241223G0001X
NY0440091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0487491OtherNYS DENTAL LICENSE
NY040046OtherNYS DENTAL LICENSE
NY029231OtherNYS DENTAL LICENSE
NY044009OtherNYS DENTAL LICENSE
NY0526781OtherNYS DENTAL LICENSE
NY032380OtherNYS DENTAL LICENSE
NY038724OtherNYS DENTAL LICENSE