Healthcare Provider Details

I. General information

NPI: 1710079371
Provider Name (Legal Business Name): ST LAWERENCE ORAL AND MAXILLIOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6604 STATE HIGHWAY 56
POTSDAM NY
13676
US

IV. Provider business mailing address

6604 STATE HIGHWAY 56
POTSDAM NY
13676
US

V. Phone/Fax

Practice location:
  • Phone: 315-265-1761
  • Fax: 315-265-1768
Mailing address:
  • Phone: 315-265-1761
  • Fax: 315-265-1768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0345831
License Number StateNY

VIII. Authorized Official

Name: ERHART A BEUTTENMULLER
Title or Position: SECRETARY
Credential: DDS
Phone: 315-265-1761