Healthcare Provider Details

I. General information

NPI: 1174944243
Provider Name (Legal Business Name): NEW BALTIMORE FAMILY DENTISTRY, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 12/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12498 RT 9W
WEST COXSACKIE NY
12192-1705
US

IV. Provider business mailing address

12498 RT 9W
WEST COXSACKIE NY
12192-1705
US

V. Phone/Fax

Practice location:
  • Phone: 518-731-2797
  • Fax: 518-731-9974
Mailing address:
  • Phone: 518-731-2797
  • Fax: 518-731-9974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number056141
License Number StateNY

VIII. Authorized Official

Name: LISA PLASS
Title or Position: OFFICE MANAGER
Credential:
Phone: 518-731-2797