Provider Demographics
NPI:1770871600
Name:KIDS & FAMILY DENTAL PC
Entity type:Organization
Organization Name:KIDS & FAMILY DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-435-0390
Mailing Address - Street 1:65 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-2630
Mailing Address - Country:US
Mailing Address - Phone:518-435-0390
Mailing Address - Fax:518-435-0379
Practice Address - Street 1:65 WOLF RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-2630
Practice Address - Country:US
Practice Address - Phone:518-435-0390
Practice Address - Fax:518-435-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-12
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052806122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty