Provider Demographics
NPI:1306929013
Name:UNIVERSITY DENTAL FACULTY PRACTICE GROUP
Entity type:Organization
Organization Name:UNIVERSITY DENTAL FACULTY PRACTICE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,MS
Authorized Official - Phone:585-275-0485
Mailing Address - Street 1:625 ELMWOOD AVE., BOX 683
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-2913
Mailing Address - Country:US
Mailing Address - Phone:585-758-0969
Mailing Address - Fax:585-475-9265
Practice Address - Street 1:2400 S CLINTON AVE STE H220
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2689
Practice Address - Country:US
Practice Address - Phone:585-341-7177
Practice Address - Fax:585-475-9265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5467OtherBLUE SHIELD
NY7309OtherBLUE SHIELD
NY7876OtherBLUE SHIELD
NYG0187522590OtherBLUE CHOICE
NY70078OtherBLUE SHIELD
NY5529OtherBLUE SHIELD
NY14482AMedicare ID - Type Unspecified