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General NPI Number Information
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NPI Number | 1023102316
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Entity Type | Organization
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Legal Business Name | DIVERSIFIED DENTAL SERVICE
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 08/12/2008
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Provider Practice Location Address
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Address Line | 2024 W HENRIETTA RD SUITE C
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City | ROCHESTER
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State | NY
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Zip | 14623-1355
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Country | US
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Telephone | 585-272-0120
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Fax | 585-272-0123
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Provider Business Mailing Address
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Address Line | 2024 W HENRIETTA RD SUITE C
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City | ROCHESTER
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State | NY
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Zip | 14623-1355
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Country | US
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Telephone | 585-272-0120
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Fax | 585-272-0123
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | MARK ALLEN LOWENGUTH
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Credential | DDS
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Telephone | 585-272-0120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 041406-01
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License Number State | NY
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