Provider Demographics
NPI:1831303569
Name:ADIRONDACK ORAL & MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:ADIRONDACK ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:LYNCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-348-0634
Mailing Address - Street 1:5 PALISADES DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-6433
Mailing Address - Country:US
Mailing Address - Phone:518-348-0634
Mailing Address - Fax:518-426-3221
Practice Address - Street 1:5 PALISADES DR
Practice Address - Street 2:SUITE 210
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-6433
Practice Address - Country:US
Practice Address - Phone:518-348-0634
Practice Address - Fax:518-426-3221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0458901223S0112X
NY0349171223S0112X
NY0498951223S0112X
NY509331223S0112X
NY0535891223S0112X
NY0559741223S0112X
NY0503841223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02117393Medicaid
NY03474224Medicaid
NY03034008Medicaid
NY00563635Medicaid
NY02781340Medicaid
NY02960649Medicaid
NY02926121Medicaid