Provider Demographics
NPI:1588973713
Name:ENDICOTT DENTAL SURGERY, PLLC
Entity type:Organization
Organization Name:ENDICOTT DENTAL SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:607-239-6400
Mailing Address - Street 1:609 E MAIN ST STE 9
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5036
Mailing Address - Country:US
Mailing Address - Phone:607-239-6400
Mailing Address - Fax:607-239-6422
Practice Address - Street 1:609 E MAIN ST STE 9
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5036
Practice Address - Country:US
Practice Address - Phone:607-239-6400
Practice Address - Fax:607-239-6422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50-052924122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty