Provider Demographics
NPI:1518047166
Name:CAPITAL DISTRICT ORAL & MAXILLOFACIAL SURGEONS,LLC
Entity type:Organization
Organization Name:CAPITAL DISTRICT ORAL & MAXILLOFACIAL SURGEONS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:PANUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-445-2505
Mailing Address - Street 1:7 SOUTHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12211-2526
Mailing Address - Country:US
Mailing Address - Phone:518-445-2505
Mailing Address - Fax:518-445-2508
Practice Address - Street 1:7 SOUTHWOODS BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12211-2526
Practice Address - Country:US
Practice Address - Phone:518-445-2505
Practice Address - Fax:518-445-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA1206Medicare PIN