Healthcare Provider Details

I. General information

NPI: 1922580455
Provider Name (Legal Business Name): JAMIE DETTMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2018
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 LAC DE VILLE BLVD
ROCHESTER NY
14618-5646
US

IV. Provider business mailing address

2301 LAC DE VILLE BLVD
ROCHESTER NY
14618-5646
US

V. Phone/Fax

Practice location:
  • Phone: 585-244-0332
  • Fax:
Mailing address:
  • Phone: 158-524-4503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number007592-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: