Provider Demographics
NPI:1659458677
Name:FONDAK DENTAL OFFICES, P.C.
Entity Type:Organization
Organization Name:FONDAK DENTAL OFFICES, P.C.
Other - Org Name:FONDAK DENTAL OFFICES, P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:FONDAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-493-9393
Mailing Address - Street 1:33054 STATE ROUTE 26
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:NY
Mailing Address - Zip Code:13619-8600
Mailing Address - Country:US
Mailing Address - Phone:315-493-9393
Mailing Address - Fax:315-493-9394
Practice Address - Street 1:33054 STATE ROUTE 26
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:NY
Practice Address - Zip Code:13619-8600
Practice Address - Country:US
Practice Address - Phone:315-493-9393
Practice Address - Fax:315-493-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0332731223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1640915OtherUNITED CONCORDIA GRP NUM
NY033273OtherNYS DENTAL LICENSE
NY1342155OtherUNITED CONCORDIA IND PROV
NY1184730392OtherNPI INDIVIDUAL NUMBER