Healthcare Provider Details

I. General information

NPI: 1851419287
Provider Name (Legal Business Name): ST. LAWRENCE ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 DEPOT STREET MARKET SQUARE MALL SUITE 17
POTSDAM NY
13676
US

IV. Provider business mailing address

22 DEPOT STREET MARKET SQUARE MALL SUITE 17
POTSDAM NY
13676-1140
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 Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: DR. ERHARD A. BEUTTENMULLER
Title or Position: SECRETARY
Credential: DDS
Phone: 315-265-1761