Healthcare Provider Details

I. General information

NPI: 1528641636
Provider Name (Legal Business Name): CODY F GORMAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 12/10/2024
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 HUDSON STREET
SOUTH GLENS FALLS NY
12803-4945
US

IV. Provider business mailing address

286 CHURCH STREET ATTN BONNIE IN CREDENTIALING
SARATOGA SPRINGS NY
12866-9208
US

V. Phone/Fax

Practice location:
  • Phone: 518-792-2187
  • Fax: 518-792-2188
Mailing address:
  • Phone: 518-584-8150
  • Fax: 518-584-8751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0-62475
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: