Healthcare Provider Details

I. General information

NPI: 1306929013
Provider Name (Legal Business Name): UNIVERSITY DENTAL FACULTY PRACTICE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 S CLINTON AVE STE H220
ROCHESTER NY
14618-2689
US

IV. Provider business mailing address

625 ELMWOOD AVE., BOX 683
ROCHESTER NY
14620-2913
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-7177
  • Fax: 585-475-9265
Mailing address:
  • Phone: 585-758-0969
  • Fax: 585-475-9265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID LEVY
Title or Position: MEDICAL DIRECTOR
Credential: DMD,MS
Phone: 585-275-0485