Provider Demographics
NPI:1629379912
Name:MENDON DENTAL CENTER
Entity Type:Organization
Organization Name:MENDON DENTAL CENTER
Other - Org Name:ANN K. KUNKEL, DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:KATHERINE
Authorized Official - Last Name:KUNKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-624-5886
Mailing Address - Street 1:30 ASSEMBLY DR
Mailing Address - Street 2:P.O. BOX 399
Mailing Address - City:MENDON
Mailing Address - State:NY
Mailing Address - Zip Code:14506-9608
Mailing Address - Country:US
Mailing Address - Phone:585-624-5886
Mailing Address - Fax:585-624-7395
Practice Address - Street 1:30 ASSEMBLY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MENDON
Practice Address - State:NY
Practice Address - Zip Code:14506-9608
Practice Address - Country:US
Practice Address - Phone:585-624-5886
Practice Address - Fax:585-624-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY420601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01143282Medicaid