Provider Demographics
NPI:1568451524
Name:VALLEY DENTAL PEDIATRICS, PC
Entity Type:Organization
Organization Name:VALLEY DENTAL PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BIGSBY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:607-754-3903
Mailing Address - Street 1:609 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ENDICOTT
Mailing Address - State:NY
Mailing Address - Zip Code:13760-5036
Mailing Address - Country:US
Mailing Address - Phone:607-754-3903
Mailing Address - Fax:607-748-4181
Practice Address - Street 1:609 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ENDICOTT
Practice Address - State:NY
Practice Address - Zip Code:13760-5036
Practice Address - Country:US
Practice Address - Phone:607-754-3903
Practice Address - Fax:607-748-4181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02370872Medicaid