Healthcare Provider Details

I. General information

NPI: 1346300209
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY & INTERCEPTIVE ORTHODONTICS P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8016 E GENESEE ST
FAYETTEVILLE NY
13066-9692
US

IV. Provider business mailing address

8016 E GENESEE ST
FAYETTEVILLE NY
13066-9692
US

V. Phone/Fax

Practice location:
  • Phone: 315-637-6961
  • Fax: 315-637-0169
Mailing address:
  • Phone: 315-637-6961
  • Fax: 315-637-0169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number027300
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number043434
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number038405
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number050957
License Number StateNY

VIII. Authorized Official

Name: DR. EDWARD ROBISON
Title or Position: TREASURER
Credential: D.D.S.
Phone: 315-637-6961