Healthcare Provider Details

I. General information

NPI: 1649388190
Provider Name (Legal Business Name): JOANN MARIE SERDINOW RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS JOANN MARIE MARKS

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 CHARLES STREET
ELMIRA NY
14902-1554
US

IV. Provider business mailing address

PO BOX 1554
ELMIRA NY
14902-1554
US

V. Phone/Fax

Practice location:
  • Phone: 607-734-7107
  • Fax: 607-734-7334
Mailing address:
  • Phone: 607-734-7107
  • Fax: 607-734-7334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number021501DUP
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: