Healthcare Provider Details

I. General information

NPI: 1417372269
Provider Name (Legal Business Name): FAMILY DENTISTRY OF LYONS, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 BROAD ST
LYONS NY
14489-1154
US

IV. Provider business mailing address

52 BROAD ST
LYONS NY
14489-1154
US

V. Phone/Fax

Practice location:
  • Phone: 585-229-2588
  • Fax:
Mailing address:
  • Phone: 585-229-2588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number053364
License Number StateNY

VIII. Authorized Official

Name: DR. EMMANUEL PUDDICOMBE
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 585-229-2588