Healthcare Provider Details

I. General information

NPI: 1407846306
Provider Name (Legal Business Name): GOUVERNEUR DENTAL ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 E MAIN ST
GOUVERNEUR NY
13642-1512
US

IV. Provider business mailing address

354 E MAIN ST PO BOX 427
GOUVERNEUR NY
13642-1512
US

V. Phone/Fax

Practice location:
  • Phone: 315-287-4000
  • Fax: 315-287-4109
Mailing address:
  • Phone: 315-287-4000
  • Fax: 315-287-4109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number040862
License Number StateNY

VIII. Authorized Official

Name: DR. SCOTT R. DAY
Title or Position: PRESIDENT
Credential: DDS
Phone: 315-287-4000