Provider Demographics
NPI:1942703251
Name:PETER GENCO
Entity Type:Organization
Organization Name:PETER GENCO
Other - Org Name:PETER GENCO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DMD
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:GENCO
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR
Authorized Official - Phone:845-434-1202
Mailing Address - Street 1:5203 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH FALLSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12779-5422
Mailing Address - Country:US
Mailing Address - Phone:845-434-1202
Mailing Address - Fax:
Practice Address - Street 1:5203 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH FALLSBURG
Practice Address - State:NY
Practice Address - Zip Code:12779-5422
Practice Address - Country:US
Practice Address - Phone:845-434-1202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049937-1261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental