Provider Demographics
NPI:1891369799
Name:EASTSIDE FAMILY DENTAL OF FAIRPORT, PC
Entity Type:Organization
Organization Name:EASTSIDE FAMILY DENTAL OF FAIRPORT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALTOBELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-223-5010
Mailing Address - Street 1:302 CROSS KEYS OFFICE PARK
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3511
Mailing Address - Country:US
Mailing Address - Phone:585-223-5010
Mailing Address - Fax:
Practice Address - Street 1:302 CROSS KEYS OFFICE PARK
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3511
Practice Address - Country:US
Practice Address - Phone:585-223-5010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-14
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1851482988OtherNPI