Provider Demographics
NPI:1598775066
Name:STEPHEN P MOONEY DDS PC
Entity Type:Organization
Organization Name:STEPHEN P MOONEY DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-331-3552
Mailing Address - Street 1:631 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1726
Mailing Address - Country:US
Mailing Address - Phone:315-331-3552
Mailing Address - Fax:315-331-1834
Practice Address - Street 1:631 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1726
Practice Address - Country:US
Practice Address - Phone:315-331-3552
Practice Address - Fax:315-331-1834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029881122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00446424Medicaid