Provider Demographics
NPI:1114658614
Name:BROCKPORT DENTAL PLLC
Entity Type:Organization
Organization Name:BROCKPORT DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:GHANEM AYOUBI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-503-0713
Mailing Address - Street 1:9 WATERBURY LN
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-1361
Mailing Address - Country:US
Mailing Address - Phone:585-503-0713
Mailing Address - Fax:
Practice Address - Street 1:1000 TRANSIT WAY # 200
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-3008
Practice Address - Country:US
Practice Address - Phone:585-957-0981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty