Healthcare Provider Details

I. General information

NPI: 1952435422
Provider Name (Legal Business Name): DIANE M GLADSTONE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 WESTFALL RD
ROCHESTER NY
14620-4610
US

IV. Provider business mailing address

3608 ARMINGTON RD
PALMYRA NY
14522-9610
US

V. Phone/Fax

Practice location:
  • Phone: 585-461-8592
  • Fax: 585-461-8580
Mailing address:
  • Phone: 315-597-5424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number041402
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: