Provider Demographics
NPI:1235676198
Name:326 TOM MILLER ROAD LLC
Entity Type:Organization
Organization Name:326 TOM MILLER ROAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CHAUVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-598-3086
Mailing Address - Street 1:326 TOM MILLER RD
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-6430
Mailing Address - Country:US
Mailing Address - Phone:518-563-7097
Mailing Address - Fax:518-563-9690
Practice Address - Street 1:326 TOM MILLER RD
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-6430
Practice Address - Country:US
Practice Address - Phone:518-563-7097
Practice Address - Fax:518-563-9690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY500515081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty