Provider Demographics
NPI:1366813313
Name:ACAHT IDENTAL PC
Entity type:Organization
Organization Name:ACAHT IDENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR/VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:607-272-2081
Mailing Address - Street 1:523 W CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5233
Mailing Address - Country:US
Mailing Address - Phone:607-272-2081
Mailing Address - Fax:
Practice Address - Street 1:523 W CLINTON ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5233
Practice Address - Country:US
Practice Address - Phone:607-272-2081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty