Provider Demographics
NPI:1215319124
Name:PEDIATRIC DENTISTRY OF POUGHKEEPSIE, PLLC
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY OF POUGHKEEPSIE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYER
Authorized Official - Middle Name:HERSH
Authorized Official - Last Name:NOSKOW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:845-454-3025
Mailing Address - Street 1:243 NORTH RD STE 1B
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1172
Mailing Address - Country:US
Mailing Address - Phone:845-454-3025
Mailing Address - Fax:845-454-3054
Practice Address - Street 1:243 NORTH RD STE 1B
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1172
Practice Address - Country:US
Practice Address - Phone:845-454-3025
Practice Address - Fax:845-454-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0556231223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03541691Medicaid