Organization
IDENTAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KARISSA PUCCI (VICE PRESIDENT)
(845) 437-4380
Entity
Organization
Contact information
Practice address
2600 SOUTH RD, SUITE 21 A, POUGHKEEPSIE, NY 12601-7003
(845) 437-4380
Mailing address
2600 SOUTH RD, SUITE 21 A, POUGHKEEPSIE, NY 12601-7003
Taxonomy
Speciality
Code
Description
License number
State
1223E0200X
Endodontics
—
—
1223P0300X
Periodontics
—
—
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
—
—
Other
Enumeration date
03/17/2009
Last updated
03/17/2009
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