1427383561 NPI number — STONE ROAD DENTAL

Table of content: (NPI 1427383561)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427383561 NPI number — STONE ROAD DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONE ROAD DENTAL
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:
1427383561
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2107 KENSINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SNYDER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14226-4807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-635-4720
Provider Business Mailing Address Fax Number:
716-635-4724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2107 KENSINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SNYDER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14226-4807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-635-4720
Provider Business Practice Location Address Fax Number:
716-635-4724
Provider Enumeration Date:
10/07/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MAIOLO
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE PERSONNEL
Authorized Official Telephone Number:
716-635-4720

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  049459-1 , 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)