Healthcare Provider Details

I. General information

NPI: 1588843106
Provider Name (Legal Business Name): CRANBERRY DENTAL MANAGEMENT CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 HAGEN DR STE 230
ROCHESTER NY
14625-2659
US

IV. Provider business mailing address

10 HAGEN DR STE 230
ROCHESTER NY
14625-2659
US

V. Phone/Fax

Practice location:
  • Phone: 585-442-1492
  • Fax: 585-586-4460
Mailing address:
  • Phone: 585-442-1492
  • Fax: 585-586-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number048025
License Number StateNY

VIII. Authorized Official

Name: MS. REBECCA RICHARDS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 585-442-1492