Provider Demographics
NPI:1720127780
Name:POWERS, MARY ELLEN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:POWERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 ROSEMONT ST
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-1001
Mailing Address - Country:US
Mailing Address - Phone:518-465-4771
Mailing Address - Fax:518-242-4770
Practice Address - Street 1:920 LARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-1300
Practice Address - Country:US
Practice Address - Phone:518-465-4771
Practice Address - Fax:518-242-4770
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006005124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY006005OtherLICENSE