Healthcare Provider Details

I. General information

NPI: 1669663316
Provider Name (Legal Business Name): MICHAEL ROBERT MOYNIHAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2007
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST GENESEE STREET SUITE #113
SYRACUSE NY
13202
US

IV. Provider business mailing address

600 EAST GENESEE STREET SUITE #113
SYRACUSE NY
13202
US

V. Phone/Fax

Practice location:
  • Phone: 315-476-7406
  • Fax: 315-476-7408
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number045676
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: