Provider First Line Business Practice Location Address:
2445 STATE ROUTE 30
Provider Second Line Business Practice Location Address:
SUNMOUNT DDSO
Provider Business Practice Location Address City Name:
TUPPER LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12986-2502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-359-7701
Provider Business Practice Location Address Fax Number:
518-359-4133
Provider Enumeration Date:
02/03/2007