Provider Demographics
NPI:1376874461
Name:W & R GEYSER RD, LLC
Entity Type:Organization
Organization Name:W & R GEYSER RD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHAUVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-885-1095
Mailing Address - Street 1:424 GEYSER RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3021
Mailing Address - Country:US
Mailing Address - Phone:518-885-1095
Mailing Address - Fax:518-885-1137
Practice Address - Street 1:424 GEYSER RD
Practice Address - Street 2:
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3021
Practice Address - Country:US
Practice Address - Phone:518-885-1095
Practice Address - Fax:518-885-1137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-29
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY32884122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00527913Medicaid