Provider Demographics
NPI:1154712677
Name:SOUTHERN TIER FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:SOUTHERN TIER FAMILY DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:MITCHENER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-665-9484
Mailing Address - Street 1:230 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FALCONER
Mailing Address - State:NY
Mailing Address - Zip Code:14733-1318
Mailing Address - Country:US
Mailing Address - Phone:716-665-9484
Mailing Address - Fax:
Practice Address - Street 1:230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FALCONER
Practice Address - State:NY
Practice Address - Zip Code:14733-1318
Practice Address - Country:US
Practice Address - Phone:716-665-9484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054513261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental