=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972271005
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROCHESTER PEDIATRIC DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2021
-----------------------------------------------------
Last Update Date | 10/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 145 SULLYS TRL STE 1
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-4561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-381-2190
-----------------------------------------------------
Fax | 585-381-2198
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 145 SULLYS TRL STE 1
-----------------------------------------------------
City | PITTSFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14534-4561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-381-2190
-----------------------------------------------------
Fax | 585-381-2198
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST
-----------------------------------------------------
Name | ERICA DIMARCO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 585-381-2190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------