Provider Demographics
NPI:1164553079
Name:BREWERTON FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BREWERTON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IMADEH
Authorized Official - Middle Name:R
Authorized Official - Last Name:NOSEGBE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:315-676-2209
Mailing Address - Street 1:PO BOX 830
Mailing Address - Street 2:
Mailing Address - City:BREWERTON
Mailing Address - State:NY
Mailing Address - Zip Code:13029-0830
Mailing Address - Country:US
Mailing Address - Phone:315-676-2209
Mailing Address - Fax:315-676-2247
Practice Address - Street 1:5501 BARTEL RD
Practice Address - Street 2:
Practice Address - City:BREWERTON
Practice Address - State:NY
Practice Address - Zip Code:13029-8701
Practice Address - Country:US
Practice Address - Phone:315-676-2209
Practice Address - Fax:315-676-2247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051614122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02570547Medicaid