Provider Demographics
NPI:1346300209
Name:PEDIATRIC DENTISTRY & INTERCEPTIVE ORTHODONTICS P.C.
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY & INTERCEPTIVE ORTHODONTICS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBISON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-637-6961
Mailing Address - Street 1:8016 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-9692
Mailing Address - Country:US
Mailing Address - Phone:315-637-6961
Mailing Address - Fax:315-637-0169
Practice Address - Street 1:8016 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-9692
Practice Address - Country:US
Practice Address - Phone:315-637-6961
Practice Address - Fax:315-637-0169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0273001223P0221X
NY0434341223P0221X
NY0384051223P0221X
NY0509571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty