=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477947786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRESTON ORTHODONTICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2015
-----------------------------------------------------
Last Update Date | 11/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2154 FAIRPORT NINE MILE POINT ROAD
-----------------------------------------------------
City | FAIRPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-880-5520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2154 FAIRPORT NINE MILE POINT ROAD
-----------------------------------------------------
City | FAIRPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-880-5520
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST/OWNER
-----------------------------------------------------
Name | DR. JANIS P PRESTON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 585-880-5520
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 052380-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------