Healthcare Provider Details

I. General information

NPI: 1467481002
Provider Name (Legal Business Name): ORTHODONTIC ASSOCIATES OF THE SOUTHERN TIER P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 E WATER ST
ELMIRA NY
14901-3411
US

IV. Provider business mailing address

440 E WATER ST
ELMIRA NY
14901-3411
US

V. Phone/Fax

Practice location:
  • Phone: 607-733-7163
  • Fax: 607-737-6227
Mailing address:
  • Phone: 607-733-7163
  • Fax: 607-737-6227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number033848
License Number StateNY

VIII. Authorized Official

Name: DR. RONALD M. BELLOHUSEN
Title or Position: PRESIDENT
Credential: DMD
Phone: 607-733-7163