Basic Information
Provider Information | |||||||||
NPI: | 1518345990 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MCDEVITT DENTAL PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 3189 | ||||||||
Address2: |   | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132203189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154546000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3432 DODGE ST | ||||||||
Address2: | SUITE 102 | ||||||||
City: | DUBUQUE | ||||||||
State: | IA | ||||||||
PostalCode: | 520035277 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5635570500 | ||||||||
FaxNumber: | 5635563294 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2015 | ||||||||
LastUpdateDate: | 05/18/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCDEVITT | ||||||||
AuthorizedOfficialFirstName: | LACEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5635570500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 8549 | IA | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.