Healthcare Provider Details

I. General information

NPI: 1134202245
Provider Name (Legal Business Name): DR. JEFFREY M. BACKER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 MOHAWK AVE
SCOTIA NY
12302-2129
US

IV. Provider business mailing address

214 MOHAWK AVE
SCOTIA NY
12302-2129
US

V. Phone/Fax

Practice location:
  • Phone: 518-377-4431
  • Fax: 518-377-0415
Mailing address:
  • Phone: 518-377-4431
  • Fax: 518-377-0415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number053596-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number036000
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number050472
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number050888
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number035839
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number051703
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number023760
License Number StateNY

VIII. Authorized Official

Name: MS. HELENE KOSSOFF
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 518-377-4431