Healthcare Provider Details

I. General information

NPI: 1720201205
Provider Name (Legal Business Name): VINGELIS AND LEE FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 OAKDALE ROAD SUITE A
JOHNSON CITY NY
13790-1766
US

IV. Provider business mailing address

145 OAKDALE ROAD SUITE A
JOHNSON CITY NY
13790-1766
US

V. Phone/Fax

Practice location:
  • Phone: 607-217-5853
  • Fax: 607-237-0159
Mailing address:
  • Phone: 607-217-5853
  • Fax: 607-237-0159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number046853-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number047633-1
License Number StateNY

VIII. Authorized Official

Name: DR. TIMOTHY JEROME LEE
Title or Position: VICE PRESIDENT
Credential: DDS
Phone: 607-754-1999