Provider Demographics
NPI:1053478743
Name:CICERO DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:CICERO DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOTTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-458-3088
Mailing Address - Street 1:7770 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:NY
Mailing Address - Zip Code:13039-8600
Mailing Address - Country:US
Mailing Address - Phone:315-458-3088
Mailing Address - Fax:315-458-5682
Practice Address - Street 1:7770 FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-8600
Practice Address - Country:US
Practice Address - Phone:315-458-3088
Practice Address - Fax:315-458-5682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031849-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00764723Medicaid
NY00461138Medicaid
NY02608079Medicaid
NY02783746Medicaid
NY02587548Medicaid
NY02134018Medicaid
NY02783686Medicaid