Provider Demographics
NPI:1548454861
Name:MIDDLETOWN DENTAL PC
Entity type:Organization
Organization Name:MIDDLETOWN DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHAPIRO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:845-343-2192
Mailing Address - Street 1:9 BERT CRAWFORD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2138
Mailing Address - Country:US
Mailing Address - Phone:845-343-2192
Mailing Address - Fax:845-342-9211
Practice Address - Street 1:9 BERT CRAWFORD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2138
Practice Address - Country:US
Practice Address - Phone:845-343-2192
Practice Address - Fax:845-342-9211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY470901223P0106X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02011076Medicaid