Provider Demographics
NPI:1083910525
Name:CANALSIDE DENTISTRY PLLC
Entity Type:Organization
Organization Name:CANALSIDE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:TOBIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:585-586-2580
Mailing Address - Street 1:69A MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-1321
Mailing Address - Country:US
Mailing Address - Phone:585-586-2580
Mailing Address - Fax:585-586-4924
Practice Address - Street 1:69A MONROE AVE
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-1321
Practice Address - Country:US
Practice Address - Phone:585-586-2580
Practice Address - Fax:585-586-4924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-01
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046826122300000X
NY051194122300000X
NY33701122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty