Healthcare Provider Details

I. General information

NPI: 1568451524
Provider Name (Legal Business Name): VALLEY DENTAL PEDIATRICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E MAIN ST
ENDICOTT NY
13760-5036
US

IV. Provider business mailing address

609 E MAIN ST
ENDICOTT NY
13760-5036
US

V. Phone/Fax

Practice location:
  • Phone: 607-754-3903
  • Fax: 607-748-4181
Mailing address:
  • Phone: 607-754-3903
  • Fax: 607-748-4181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number30430
License Number StateNY

VIII. Authorized Official

Name: DR. GARY W. BIGSBY
Title or Position: DOCTOR
Credential: DMD
Phone: 607-754-3903