Provider Demographics
NPI:1417372269
Name:FAMILY DENTISTRY OF LYONS, P.C
Entity Type:Organization
Organization Name:FAMILY DENTISTRY OF LYONS, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PUDDICOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-229-2588
Mailing Address - Street 1:52 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-1154
Mailing Address - Country:US
Mailing Address - Phone:585-229-2588
Mailing Address - Fax:
Practice Address - Street 1:52 BROAD ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-1154
Practice Address - Country:US
Practice Address - Phone:585-229-2588
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053364122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02605329Medicaid