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General NPI Number Information
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NPI Number | 1801156674
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Entity Type | Organization
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Legal Business Name | OAKDALE MALL DENTAL LLP
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Dates
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Enumeration Date | 05/25/2012
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Last Update Date | 05/25/2012
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Provider Practice Location Address
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Address Line | 601-635 HARRY L DR 46
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City | JOHNSON CITY
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State | NY
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Zip | 13790-1246
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Country | US
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Telephone | 607-770-8888
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Fax | 607-770-8881
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Provider Business Mailing Address
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Address Line | 601-635 HARRY L DR 46
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City | JOHNSON CITY
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State | NY
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Zip | 13790-1246
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Country | US
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Telephone | 607-770-8888
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Fax | 607-770-8881
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Authorized Official
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Title or Position | OWNER
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Name | ROSS KRASNOV
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Credential | DDS
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Telephone | 607-770-8888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 046043
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License Number State | NY
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