Provider Demographics
NPI:1770653412
Name:WATERTOWN DENTAL HEALTH GROUP, PC
Entity Type:Organization
Organization Name:WATERTOWN DENTAL HEALTH GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-788-1070
Mailing Address - Street 1:1131 COMMERCE PARK DR E
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2279
Mailing Address - Country:US
Mailing Address - Phone:315-788-1070
Mailing Address - Fax:315-785-1039
Practice Address - Street 1:1131 COMMERCE PARK DR E
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2279
Practice Address - Country:US
Practice Address - Phone:315-788-1070
Practice Address - Fax:315-785-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty