Basic Information
| Provider Information | |||||||||
| NPI: | 1477889178 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASPEN DENTAL OF CENTRAL NEW YORK, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 281 SANDERS CREEK PKWY | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130571307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
| FaxNumber: | 3154548650 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 NORTHERN LIGHTS DR | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132124108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154542411 | ||||||||
| FaxNumber: | 3154552412 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2009 | ||||||||
| LastUpdateDate: | 11/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | HAMATI | ||||||||
| AuthorizedOfficialFirstName: | ISAM | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3154552411 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 047142-1 | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.