Healthcare Provider Details

I. General information

NPI: 1992926257
Provider Name (Legal Business Name): PAUL CASEY FALLON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 W TAFT RD
LIVERPOOL NY
13088-2800
US

IV. Provider business mailing address

7026 HIGHFIELD RD
FAYETTEVILLE NY
13066-9724
US

V. Phone/Fax

Practice location:
  • Phone: 315-451-6988
  • Fax:
Mailing address:
  • Phone: 315-478-7316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number046001
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: