Provider Demographics
NPI:1457869224
Name:TICONDEROGA DENTAL PLAZA, PC
Entity type:Organization
Organization Name:TICONDEROGA DENTAL PLAZA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:FEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:518-825-0025
Mailing Address - Street 1:304 W BAY PLZ
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1787
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1019 WICKER ST
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-1039
Practice Address - Country:US
Practice Address - Phone:518-825-0025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0006491223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDental AnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherEIN #