Provider Demographics
NPI:1700943750
Name:AMERICAN MOBILE DENTAL, P.C.
Entity Type:Organization
Organization Name:AMERICAN MOBILE DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WENCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-835-6004
Mailing Address - Street 1:76 PROGRESS DR STE 123
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3603
Mailing Address - Country:US
Mailing Address - Phone:914-835-6004
Mailing Address - Fax:914-835-6055
Practice Address - Street 1:8 GRAND ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:NY
Practice Address - Zip Code:13820-2624
Practice Address - Country:US
Practice Address - Phone:607-432-1010
Practice Address - Fax:914-835-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02636877Medicaid