Provider Demographics
NPI:1588104376
Name:PINE BUSH DENTAL GROUP
Entity type:Organization
Organization Name:PINE BUSH DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DDS
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:FABER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-744-5422
Mailing Address - Street 1:809 STATE ROUTE 208
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-1829
Mailing Address - Country:US
Mailing Address - Phone:845-782-5040
Mailing Address - Fax:
Practice Address - Street 1:2412 ROUTE 52
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-7037
Practice Address - Country:US
Practice Address - Phone:845-744-5422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0557181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY3399442Medicaid