Provider Demographics
NPI:1811121379
Name:IDENT DENTAL AT MIDDLETOWN
Entity type:Organization
Organization Name:IDENT DENTAL AT MIDDLETOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SPOSATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-245-4332
Mailing Address - Street 1:453 ROUTE 211 E
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2206
Mailing Address - Country:US
Mailing Address - Phone:888-433-6820
Mailing Address - Fax:
Practice Address - Street 1:453 ROUTE 211 E
Practice Address - Street 2:SUITE 103
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2206
Practice Address - Country:US
Practice Address - Phone:888-433-6820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0483281223E0200X
NY0517321223P0300X
NY0499671223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty