Provider Demographics
NPI:1427336866
Name:FAYETTEVILLE DENTAL ASSOCIATES
Entity type:Organization
Organization Name:FAYETTEVILLE DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-409-5290
Mailing Address - Street 1:7000 EAST GENESEE STREET
Mailing Address - Street 2:BUILDING D
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-445-1321
Mailing Address - Fax:315-445-1399
Practice Address - Street 1:7000 E GENESEE ST
Practice Address - Street 2:BUILDING D
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1131
Practice Address - Country:US
Practice Address - Phone:315-445-1321
Practice Address - Fax:315-445-1399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00461138Medicaid