Healthcare Provider Details

I. General information

NPI: 1669701314
Provider Name (Legal Business Name): JOLLY CAPLASH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2009
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 HARVEST GLN
PITTSFORD NY
14534-2769
US

IV. Provider business mailing address

5 HARVEST GLN
PITTSFORD NY
14534-2769
US

V. Phone/Fax

Practice location:
  • Phone: 585-414-6463
  • Fax:
Mailing address:
  • Phone: 585-414-6463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number048025
License Number StateNY

VIII. Authorized Official

Name: JOLLY N CAPLASH
Title or Position: ORAL SURGEON
Credential:
Phone: 585-414-6463