Provider Demographics
NPI:1114078268
Name:TIOGA COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:TIOGA COUNTY HEALTH DEPARTMENT
Other - Org Name:DENTAL VAN
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCCANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-687-8604
Mailing Address - Street 1:1062 STATE RTE 38
Mailing Address - Street 2:
Mailing Address - City:OWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13827-0120
Mailing Address - Country:US
Mailing Address - Phone:607-687-8600
Mailing Address - Fax:607-687-2916
Practice Address - Street 1:1062 STATE RTE 38
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827-0120
Practice Address - Country:US
Practice Address - Phone:607-687-8600
Practice Address - Fax:607-687-2916
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TIOGA COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY53234200R251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00356294Medicaid