Provider Demographics
NPI:1669649166
Name:EAST AVENUE DENTISTRY PLLC
Entity Type:Organization
Organization Name:EAST AVENUE DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-586-5480
Mailing Address - Street 1:1641 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1616
Mailing Address - Country:US
Mailing Address - Phone:585-482-5504
Mailing Address - Fax:585-482-5507
Practice Address - Street 1:1641 EAST AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1616
Practice Address - Country:US
Practice Address - Phone:585-482-5504
Practice Address - Fax:585-482-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032910261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental