Provider Demographics
NPI:1063678613
Name:LEGACY DENTAL PRACTICE PLLC
Entity Type:Organization
Organization Name:LEGACY DENTAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:GUSMEROTTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-720-1370
Mailing Address - Street 1:31 ERIE CANAL DR
Mailing Address - Street 2:SUITE H
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-4602
Mailing Address - Country:US
Mailing Address - Phone:585-720-1370
Mailing Address - Fax:
Practice Address - Street 1:190 FERGUSON DR
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-9504
Practice Address - Country:US
Practice Address - Phone:585-720-1370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1477611432OtherNPPES