Provider Demographics
NPI:1053471391
Name:WADING RIVER COMPLETE DENTAL CARE PC
Entity Type:Organization
Organization Name:WADING RIVER COMPLETE DENTAL CARE PC
Other - Org Name:CLIFFORD BAYNON DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:BAYNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:631-929-8709
Mailing Address - Street 1:6278 ROUTE 25A
Mailing Address - Street 2:
Mailing Address - City:WADING RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:11792
Mailing Address - Country:US
Mailing Address - Phone:631-929-8709
Mailing Address - Fax:631-929-8371
Practice Address - Street 1:6278 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:WADING RIVER
Practice Address - State:NY
Practice Address - Zip Code:11792
Practice Address - Country:US
Practice Address - Phone:631-929-8709
Practice Address - Fax:631-929-8371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty