Provider Demographics
NPI:1922336973
Name:ST LAWRENCE DENTAL STUDIO PLLC
Entity Type:Organization
Organization Name:ST LAWRENCE DENTAL STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDVED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-379-9195
Mailing Address - Street 1:119 MINER RD
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-6103
Mailing Address - Country:US
Mailing Address - Phone:518-483-8157
Mailing Address - Fax:
Practice Address - Street 1:14 MINER ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1286
Practice Address - Country:US
Practice Address - Phone:315-379-9195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty