Healthcare Provider Details

I. General information

NPI: 1255495263
Provider Name (Legal Business Name): OGDENSBURG DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 STATE STREET
OGDENSBURG NY
13669-2647
US

IV. Provider business mailing address

224 NEW YORK AVENUE
OGDENSBURG NY
13669-2647
US

V. Phone/Fax

Practice location:
  • Phone: 315-394-1000
  • Fax: 315-393-9221
Mailing address:
  • Phone: 315-394-1000
  • Fax: 315-393-9221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0457721
License Number StateNY

VIII. Authorized Official

Name: ABDUL MAJEED
Title or Position: OWNER
Credential: DENTAL DDS
Phone: 315-394-1000