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General NPI Number Information
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NPI Number | 1083910525
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Entity Type | Organization
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Legal Business Name | CANALSIDE DENTISTRY PLLC
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Dates
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Enumeration Date | 02/01/2011
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Last Update Date | 01/11/2012
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Provider Practice Location Address
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Address Line | 69A MONROE AVE
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City | PITTSFORD
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State | NY
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Zip | 14534-1321
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Country | US
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Telephone | 585-586-2580
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Fax | 585-586-4924
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Provider Business Mailing Address
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Address Line | 69A MONROE AVE
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City | PITTSFORD
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State | NY
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Zip | 14534-1321
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Country | US
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Telephone | 585-586-2580
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Fax | 585-586-4924
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Authorized Official
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Title or Position | PARTNER/MEMBER
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Name | DR. MARY JO TOBIN
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Credential | DMD
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Telephone | 585-586-2580
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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 | 051194
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 33701
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License Number State | NY
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 046826
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License Number State | NY
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