Provider Demographics
NPI:1093845430
Name:VILLAGE DENTAL GROUP OF CENTRAL SQUARE
Entity Type:Organization
Organization Name:VILLAGE DENTAL GROUP OF CENTRAL SQUARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-676-3001
Mailing Address - Street 1:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:CENTRAL SQUARE
Mailing Address - State:NY
Mailing Address - Zip Code:13036-0369
Mailing Address - Country:US
Mailing Address - Phone:315-676-3001
Mailing Address - Fax:315-676-3785
Practice Address - Street 1:537 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRAL SQUARE
Practice Address - State:NY
Practice Address - Zip Code:13036-3500
Practice Address - Country:US
Practice Address - Phone:315-676-3001
Practice Address - Fax:315-676-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty