Healthcare Provider Details

I. General information

NPI: 1811083124
Provider Name (Legal Business Name): SG DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 COUNTY ROUTE 57 THREE RIVERS PLAZA
PHOENIX NY
13135-3300
US

IV. Provider business mailing address

219 COUNTY ROUTE 57 THREE RIVERS PLAZA
PHOENIX NY
13135-3300
US

V. Phone/Fax

Practice location:
  • Phone: 315-695-2128
  • Fax:
Mailing address:
  • Phone: 315-695-2128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number032076
License Number StateNY

VIII. Authorized Official

Name: DR. SHARADCHANDRA GHANASHYAM DESAI
Title or Position: PRESIDENT
Credential: BDS
Phone: 315-695-2128