Healthcare Provider Details

I. General information

NPI: 1184868119
Provider Name (Legal Business Name): ANDREW ADAM BEUTTENMULLER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22645 SUMMIT DRIVE
WATERTOWN NY
13601
US

IV. Provider business mailing address

182 BOWERS AVE
WATERTOWN NY
13601-4028
US

V. Phone/Fax

Practice location:
  • Phone: 315-221-4044
  • Fax:
Mailing address:
  • Phone: 716-352-3088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number055594
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: