Provider Demographics
NPI:1083195754
Name:SOUTHERN TIER DENTISTRY
Entity Type:Organization
Organization Name:SOUTHERN TIER DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WINCHESTER
Authorized Official - Middle Name:LOGAN
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-763-6823
Mailing Address - Street 1:133 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1950
Mailing Address - Country:US
Mailing Address - Phone:716-763-6823
Mailing Address - Fax:716-763-0341
Practice Address - Street 1:133 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1950
Practice Address - Country:US
Practice Address - Phone:716-763-6823
Practice Address - Fax:716-763-0341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental