Provider Demographics
NPI:1346377017
Name:DAVID J DEXTER OD PC
Entity Type:Organization
Organization Name:DAVID J DEXTER OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEXTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:315-298-6966
Mailing Address - Street 1:PO BOX 196
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-0196
Mailing Address - Country:US
Mailing Address - Phone:315-298-6966
Mailing Address - Fax:
Practice Address - Street 1:3333 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:NY
Practice Address - Zip Code:13142-2561
Practice Address - Country:US
Practice Address - Phone:315-298-6966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003632152W00000X
NY006508152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02581597Medicaid
NYDF4300OtherPALMETTO GBA-RAILROAD MC
NYAA1302Medicare PIN
NYDF4300OtherPALMETTO GBA-RAILROAD MC