Provider Demographics
NPI:1104913318
Name:COURT STREET DENTAL, PC
Entity type:Organization
Organization Name:COURT STREET DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:HECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-342-5456
Mailing Address - Street 1:310 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4221
Mailing Address - Country:US
Mailing Address - Phone:607-342-5456
Mailing Address - Fax:607-272-3757
Practice Address - Street 1:310 E COURT ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4221
Practice Address - Country:US
Practice Address - Phone:607-272-2033
Practice Address - Fax:607-272-3757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental