=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912919184
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDODONTIC ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 EAST GENESEE ST SUITE 113
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-476-7406
-----------------------------------------------------
Fax | 315-476-7408
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 EAST GENESEE ST SUITE 113
-----------------------------------------------------
City | SYRACUSE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-476-7406
-----------------------------------------------------
Fax | 315-476-7408
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JEFFREY H STEIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 315-476-7406
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 040784
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------