Healthcare Provider Details

I. General information

NPI: 1861567554
Provider Name (Legal Business Name): ADIRONDACK FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7990 STATE RTE 12 SUITE 1
BARNEVELD NY
13304
US

IV. Provider business mailing address

7990 STATE RTE 12 SUITE 1
BARNEVELD NY
13304
US

V. Phone/Fax

Practice location:
  • Phone: 315-896-7293
  • Fax: 315-896-7294
Mailing address:
  • Phone: 315-896-7293
  • Fax: 315-896-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0474871
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0474861
License Number StateNY

VIII. Authorized Official

Name: DR. EVERETT M STALKER
Title or Position: OWNER VICE PRESIDENT
Credential: DDS
Phone: 315-896-7293