Healthcare Provider Details

I. General information

NPI: 1144266222
Provider Name (Legal Business Name): CYNTHIA KATHRYN SLACK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 BEAHAN ROAD WESTGATE WOODS
ROCHESTER NY
14624
US

IV. Provider business mailing address

523 BEAHAN ROAD WESTGATE WOODS
ROCHESTER NY
14624
US

V. Phone/Fax

Practice location:
  • Phone: 585-426-2550
  • Fax: 585-426-4118
Mailing address:
  • Phone: 585-426-2550
  • Fax: 585-426-4118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number035772
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: