=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467984229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WASHINGTON FAMILY DENTAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2017
-----------------------------------------------------
Last Update Date | 03/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 WASHINGTON AVE
-----------------------------------------------------
City | ENDICOTT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13760-5354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-785-1027
-----------------------------------------------------
Fax | 607-785-0269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 WASHINGTON AVE
-----------------------------------------------------
City | ENDICOTT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13760-5354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-785-1027
-----------------------------------------------------
Fax | 607-785-0269
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GUILLERMO E. RAMOS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 607-785-1027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 046818
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------