Provider Demographics
NPI:1205079282
Name:EXCELDENT OF ORANGE SULLIVAN
Entity type:Organization
Organization Name:EXCELDENT OF ORANGE SULLIVAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-794-0706
Mailing Address - Street 1:523 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-1111
Mailing Address - Country:US
Mailing Address - Phone:845-794-0706
Mailing Address - Fax:845-794-0606
Practice Address - Street 1:523 BROADWAY
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701
Practice Address - Country:US
Practice Address - Phone:845-794-0706
Practice Address - Fax:845-794-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-07
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050306122300000X
NY054091122300000X
PA044624-1122300000X
NY0269061223S0112X
NY041682-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty