=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104932235
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEINSTEIN DENTAL GROUP, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 WEST AVE
-----------------------------------------------------
City | BROCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14420-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-637-4330
-----------------------------------------------------
Fax | 585-637-4858
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 375 WEST AVE
-----------------------------------------------------
City | BROCKPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14420-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-637-4330
-----------------------------------------------------
Fax | 585-637-4858
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. STEPHEN WEINSTEIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 585-637-4330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 050041-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 029598-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------