Provider Demographics
NPI:1912338674
Name:UPSTATE NEW YORK DENTAL PC
Entity type:Organization
Organization Name:UPSTATE NEW YORK DENTAL PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NANARAO
Authorized Official - Middle Name:
Authorized Official - Last Name:KROTHAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-223-1652
Mailing Address - Street 1:30 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13901-2332
Mailing Address - Country:US
Mailing Address - Phone:607-238-1280
Mailing Address - Fax:
Practice Address - Street 1:30 W STATE ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2332
Practice Address - Country:US
Practice Address - Phone:607-238-1280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-06
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056567-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03586427Medicaid