Provider Demographics
NPI:1710079371
Name:ST LAWERENCE ORAL AND MAXILLIOFACIAL SURGERY
Entity Type:Organization
Organization Name:ST LAWERENCE ORAL AND MAXILLIOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ERHART
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEUTTENMULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-265-1761
Mailing Address - Street 1:6604 STATE HIGHWAY 56
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676
Mailing Address - Country:US
Mailing Address - Phone:315-265-1761
Mailing Address - Fax:315-265-1768
Practice Address - Street 1:6604 STATE HIGHWAY 56
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676
Practice Address - Country:US
Practice Address - Phone:315-265-1761
Practice Address - Fax:315-265-1768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03458311223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01456399Medicaid