Provider Demographics
NPI:1215245964
Name:CYNTHIA K SLACK DDS PC
Entity type:Organization
Organization Name:CYNTHIA K SLACK DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SLACK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-426-2550
Mailing Address - Street 1:523 BEAHAN RD
Mailing Address - Street 2:WESTGATE WOOD PROFESSIONAL COMPLEX
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14624-3403
Mailing Address - Country:US
Mailing Address - Phone:585-426-2550
Mailing Address - Fax:585-426-4118
Practice Address - Street 1:523 BEAHAN RD
Practice Address - Street 2:WESTGATE WOOD PROFESSIONAL COMPLEX
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14624-3403
Practice Address - Country:US
Practice Address - Phone:585-426-2550
Practice Address - Fax:585-426-4118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0357721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1144266222Medicaid