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General NPI Number Information
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NPI Number | 1063678613
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Entity Type | Organization
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Legal Business Name | LEGACY DENTAL PRACTICE PLLC
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Dates
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Enumeration Date | 08/04/2008
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Last Update Date | 08/04/2008
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Provider Practice Location Address
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Address Line | 190 FERGUSON DR
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City | HILTON
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State | NY
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Zip | 14468-9504
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Country | US
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Telephone | 585-720-1370
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Fax |
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Provider Business Mailing Address
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Address Line | 31 ERIE CANAL DR SUITE H
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City | ROCHESTER
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State | NY
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Zip | 14626-4602
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Country | US
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Telephone | 585-720-1370
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GARY LOUIS GUSMEROTTI
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Credential | DDS
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Telephone | 585-720-1370
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 053408
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License Number State | NY
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