Healthcare Provider Details

I. General information

NPI: 1225635881
Provider Name (Legal Business Name): LAKE CHAMPLAIN DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 BOYNTON AVE STE 2
PLATTSBURGH NY
12901-1268
US

IV. Provider business mailing address

37 BOYNTON AVE STE 2
PLATTSBURGH NY
12901-1268
US

V. Phone/Fax

Practice location:
  • Phone: 518-563-5002
  • Fax: 518-563-5911
Mailing address:
  • Phone: 518-563-5002
  • Fax: 518-563-5911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JOEL ABIKHZER
Title or Position: OWNER/DENTIST
Credential: DMD
Phone: 518-563-5002