Provider Demographics
NPI:1770011728
Name:MARY ANN PANARA DDS AND JEFFREY P PANARA DDS
Entity Type:Organization
Organization Name:MARY ANN PANARA DDS AND JEFFREY P PANARA DDS
Other - Org Name:FAIRPORT FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARRY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PANARA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-223-9323
Mailing Address - Street 1:83 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-2161
Mailing Address - Country:US
Mailing Address - Phone:585-223-9323
Mailing Address - Fax:585-223-0702
Practice Address - Street 1:83 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-2161
Practice Address - Country:US
Practice Address - Phone:585-223-9323
Practice Address - Fax:585-223-0702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0446041223G0001X, 332BC3200X
NY0434421223G0001X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7040OtherEXCELLUS
NY7239OtherEXCELLUS