Provider Demographics
NPI:1891825600
Name:MARUSICH & CONTI DENTAL, PLLC
Entity Type:Organization
Organization Name:MARUSICH & CONTI DENTAL, PLLC
Other - Org Name:COLUMBIA DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:CONTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:607-770-1122
Mailing Address - Street 1:515 COLUMBIA DRIVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790
Mailing Address - Country:US
Mailing Address - Phone:607-770-1122
Mailing Address - Fax:607-770-1176
Practice Address - Street 1:515 COLUMBIA DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:607-770-1122
Practice Address - Fax:607-770-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0414091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY104448556Medicaid