Healthcare Provider Details

I. General information

NPI: 1629342860
Provider Name (Legal Business Name): THOMAS P. MCCUE IV DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 S MAIN ST
PHILADELPHIA NY
13673-9998
US

IV. Provider business mailing address

2 S MAIN ST
PHILADELPHIA NY
13673-9998
US

V. Phone/Fax

Practice location:
  • Phone: 315-642-0318
  • Fax: 315-642-0614
Mailing address:
  • Phone: 315-642-0318
  • Fax: 315-642-0614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number053972
License Number StateNY

VIII. Authorized Official

Name: MS. CAMMIE LYNDAKER
Title or Position: OFFICE MANAGER
Credential: HGN
Phone: 315-642-0318