Healthcare Provider Details

I. General information

NPI: 1013009968
Provider Name (Legal Business Name): THOMAS J FALLON D.D.S.P.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 W TAFT RD SUITE #3M NORTH MEDICAL CENTER
LIVERPOOL NY
13088-3807
US

IV. Provider business mailing address

5100 W TAFT RD SUITE #3M
LIVERPOOL NY
13088-3807
US

V. Phone/Fax

Practice location:
  • Phone: 315-452-2570
  • Fax: 315-452-2573
Mailing address:
  • Phone: 315-452-2570
  • Fax: 315-452-2573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number032133-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: