MEDICARE: DENTULA DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1720829732
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTULA DENTAL

Provider Business Mailing Address
First Line	:	183 GENESEE ST
Second Line	:
City	:	AUBURN
State	:	NY
Zip	:	13021-3370
Country	:	US
Telephone Number	:	315-253-7384
Fax Number	:

Provider Business Practice Location Address
First Line	:	183 GENESEE ST
Second Line	:
City	:	AUBURN
State	:	NY
Zip	:	13021-3370
Country	:	US
Telephone Number	:	315-253-7384
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	RAYANNE KEATING
Credential	:
Telephone Number	:	315-253-7384

Provider Enumeration Date	:	06/04/2024
Last Update Date	:	06/04/2024

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