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General NPI Number Information
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NPI Number | 1497263685
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Entity Type | Organization
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Legal Business Name | 1500 GRANT BLVD DENTISTRY, PLLC
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Dates
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Enumeration Date | 01/22/2018
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Last Update Date | 01/22/2018
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Provider Practice Location Address
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Address Line | 1500 GRANT BLVD
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City | SYRACUSE
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State | NY
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Zip | 13208-3014
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Country | US
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Telephone | 315-472-3414
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Fax | 315-472-4320
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Provider Business Mailing Address
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Address Line | 1500 GRANT BLVD
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City | SYRACUSE
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State | NY
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Zip | 13208-3014
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Country | US
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Telephone | 315-472-3414
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Fax | 315-472-4320
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Authorized Official
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Title or Position | CEO
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Name | ARUN BALAKUMAR
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Credential | DDS
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Telephone | 315-472-3414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 051141
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License Number State | NY
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