=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659497436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINELLI DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2007
-----------------------------------------------------
Last Update Date | 07/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2070 LYELL AVE STE.200
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14606-5715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-458-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2070 LYELL AVE STE.200
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14606-5715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-458-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GLEN M SPINELLI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 585-458-5700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 042883
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------