Provider Demographics
NPI:1134202245
Name:DR. JEFFREY M. BACKER
Entity type:Organization
Organization Name:DR. JEFFREY M. BACKER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HELENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSSOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-377-4431
Mailing Address - Street 1:214 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-2129
Mailing Address - Country:US
Mailing Address - Phone:518-377-4431
Mailing Address - Fax:518-377-0415
Practice Address - Street 1:214 MOHAWK AVE
Practice Address - Street 2:
Practice Address - City:SCOTIA
Practice Address - State:NY
Practice Address - Zip Code:12302-2129
Practice Address - Country:US
Practice Address - Phone:518-377-4431
Practice Address - Fax:518-377-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0504721223G0001X
NY0508881223G0001X
NY0358391223G0001X
NY0517031223G0001X
NY0237601223X0400X
NY053596-1122300000X
NY0360001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty