Healthcare Provider Details

I. General information

NPI: 1851896567
Provider Name (Legal Business Name): CENTRAL SQUARE SMILES DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 03/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 S MAIN ST
CENTRAL SQUARE NY
13036
US

IV. Provider business mailing address

653 S MAIN ST
CENTRAL SQUARE NY
13036
US

V. Phone/Fax

Practice location:
  • Phone: 315-668-6261
  • Fax:
Mailing address:
  • Phone: 315-668-6261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: KIMBER CUMMINGS
Title or Position: OFFICE MANAGER
Credential: RDH
Phone: 315-638-0276