Provider Demographics
NPI:1649769159
Name:ROCHESTER FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:ROCHESTER FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:SY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:520-907-9383
Mailing Address - Street 1:2209 POETS DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:IN
Mailing Address - Zip Code:46975-9011
Mailing Address - Country:US
Mailing Address - Phone:520-907-9383
Mailing Address - Fax:
Practice Address - Street 1:1014 MADISON ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:IN
Practice Address - Zip Code:46975-1830
Practice Address - Country:US
Practice Address - Phone:520-907-9383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011491A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental