MEDICARE: PEDERSEN DENTISTRY, PLLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1679231591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDERSEN DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	18 ALAMEDA DR
Second Line	:
City	:	FAIRPORT
State	:	NY
Zip	:	14450-8790
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 WESTFALL RD
Second Line	:
City	:	ROCHESTER
State	:	NY
Zip	:	14620-4606
Country	:	US
Telephone Number	:	585-473-3880
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. TODD RICHARD PEDERSEN
Credential	:	DDS
Telephone Number	:	585-469-5433

Provider Enumeration Date	:	12/08/2021
Last Update Date	:	12/08/2021

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