Provider Demographics
NPI:1952558074
Name:COUNTRYSIDE DENTAL
Entity Type:Organization
Organization Name:COUNTRYSIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMENIC
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCOBONO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-392-5231
Mailing Address - Street 1:42 KINDERHOOK ST
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12037-1207
Mailing Address - Country:US
Mailing Address - Phone:518-392-5231
Mailing Address - Fax:518-392-7339
Practice Address - Street 1:42 KINDERHOOK ST
Practice Address - Street 2:
Practice Address - City:CHATHAM
Practice Address - State:NY
Practice Address - Zip Code:12037-1207
Practice Address - Country:US
Practice Address - Phone:518-392-5231
Practice Address - Fax:518-392-7339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0459411223G0001X
NY0392711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty