Healthcare Provider Details

I. General information

NPI: 1538591276
Provider Name (Legal Business Name): MENDON DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 ASSEMBLY DR STE 102
MENDON NY
14506-9608
US

IV. Provider business mailing address

30 ASSEMBLY DR STE 102 P.O. BOX 399
MENDON NY
14506-9608
US

V. Phone/Fax

Practice location:
  • Phone: 585-624-5886
  • Fax: 585-624-7395
Mailing address:
  • Phone: 585-624-5886
  • Fax: 585-624-7395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number054386
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number054966
License Number StateNY

VIII. Authorized Official

Name: DR. JAMES N ROLAND
Title or Position: OWNER
Credential: DDS
Phone: 585-624-5886