Provider Demographics
NPI:1497907448
Name:UNION STREET DENTISTRY
Entity type:Organization
Organization Name:UNION STREET DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SANTA MARIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-346-6429
Mailing Address - Street 1:1740 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12309-6233
Mailing Address - Country:US
Mailing Address - Phone:518-346-6429
Mailing Address - Fax:518-346-8495
Practice Address - Street 1:1740 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12309-6233
Practice Address - Country:US
Practice Address - Phone:518-346-6429
Practice Address - Fax:518-346-8495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051914-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051925-1OtherNEW YORK LICENSE
NY046910-1OtherNEW YORK LICENSE
NY051914-1OtherNY LICENSE NUMBER