1710079371 NPI number — ST LAWERENCE ORAL AND MAXILLIOFACIAL SURGERY

Table of content: (NPI 1710079371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710079371 NPI number — ST LAWERENCE ORAL AND MAXILLIOFACIAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST LAWERENCE ORAL AND MAXILLIOFACIAL SURGERY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710079371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6604 STATE HIGHWAY 56
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTSDAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13676
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-265-1761
Provider Business Mailing Address Fax Number:
315-265-1768

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6604 STATE HIGHWAY 56
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTSDAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-265-1761
Provider Business Practice Location Address Fax Number:
315-265-1768
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BEUTTENMULLER
Authorized Official First Name:
ERHART
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
315-265-1761

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  0345831 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01456399 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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