Provider Demographics
NPI:1407846306
Name:GOUVERNEUR DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:GOUVERNEUR DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-287-4000
Mailing Address - Street 1:354 E MAIN ST
Mailing Address - Street 2:PO BOX 427
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1512
Mailing Address - Country:US
Mailing Address - Phone:315-287-4000
Mailing Address - Fax:315-287-4109
Practice Address - Street 1:354 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1512
Practice Address - Country:US
Practice Address - Phone:315-287-4000
Practice Address - Fax:315-287-4109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040862122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01134569Medicaid
NY02572989Medicaid