=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053084376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONEIDA ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2021
-----------------------------------------------------
Last Update Date | 08/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 306 W LIBERTY ST
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13440-5744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-336-6380
-----------------------------------------------------
Fax | 315-338-0861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 306 W LIBERTY ST
-----------------------------------------------------
City | ROME
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13440-5744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-336-6380
-----------------------------------------------------
Fax | 315-338-0861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FINANCIAL COORDINATO
-----------------------------------------------------
Name | KARMIE WILEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 315-336-6380
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------