Provider Demographics
NPI:1548879687
Name:DUANE AVENUE DENTAL CARE, PC
Entity type:Organization
Organization Name:DUANE AVENUE DENTAL CARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:STASKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-895-8006
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:DUANESBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12056-0177
Mailing Address - Country:US
Mailing Address - Phone:518-895-8006
Mailing Address - Fax:
Practice Address - Street 1:181 DUANE AVENUE
Practice Address - Street 2:
Practice Address - City:DUANESBURG
Practice Address - State:NY
Practice Address - Zip Code:12056
Practice Address - Country:US
Practice Address - Phone:518-895-8006
Practice Address - Fax:518-895-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty