MEDICARE: CHOICE DENTAL P.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	045344	NY

General Provider Information

NPI Number	:	1376811521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOICE DENTAL P.C

Provider Business Mailing Address
First Line	:	4188 LAKEVILLE RD
Second Line	:
City	:	GENESEO
State	:	NY
Zip	:	14454-1134
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4188 LAKEVILLE RD
Second Line	:
City	:	GENESEO
State	:	NY
Zip	:	14454-1134
Country	:	US
Telephone Number	:	917-744-3131
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EMIL BLANK
Credential	:
Telephone Number	:	19177443131

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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