Healthcare Provider Details

I. General information

NPI: 1023102316
Provider Name (Legal Business Name): DIVERSIFIED DENTAL SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2024 W HENRIETTA RD SUITE C
ROCHESTER NY
14623-1355
US

IV. Provider business mailing address

2024 W HENRIETTA RD SUITE C
ROCHESTER NY
14623-1355
US

V. Phone/Fax

Practice location:
  • Phone: 585-272-0120
  • Fax: 585-272-0123
Mailing address:
  • Phone: 585-272-0120
  • Fax: 585-272-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number041406-01
License Number StateNY

VIII. Authorized Official

Name: MARK ALLEN LOWENGUTH
Title or Position: DENTIST/OWNER
Credential: DDS
Phone: 585-272-0120