=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659458677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FONDAK DENTAL OFFICES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 33054 STATE ROUTE 26
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13619-8600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-493-9393
-----------------------------------------------------
Fax | 315-493-9394
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33054 STATE ROUTE 26
-----------------------------------------------------
City | CARTHAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13619-8600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-493-9393
-----------------------------------------------------
Fax | 315-493-9394
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY THEODORE FONDAK
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 315-493-9393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 033273
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------