Provider Demographics
NPI:1275781767
Name:MARCELLUS FAMILY AND COSMETIC DENTISTRY, PC
Entity Type:Organization
Organization Name:MARCELLUS FAMILY AND COSMETIC DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:H
Authorized Official - Last Name:RAO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-673-1131
Mailing Address - Street 1:28 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARCELLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13108-1226
Mailing Address - Country:US
Mailing Address - Phone:315-673-1131
Mailing Address - Fax:315-673-2624
Practice Address - Street 1:28 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MARCELLUS
Practice Address - State:NY
Practice Address - Zip Code:13108-1226
Practice Address - Country:US
Practice Address - Phone:315-673-1131
Practice Address - Fax:315-673-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045518-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00832669OtherUNITED CONCORDIA
NY02549695Medicaid
00832669OtherUNITED CONCORDIA
NYRA5489Medicare PIN