Provider Demographics
NPI:1023102316
Name:DIVERSIFIED DENTAL SERVICE
Entity type:Organization
Organization Name:DIVERSIFIED DENTAL SERVICE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:LOWENGUTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-272-0120
Mailing Address - Street 1:2024 W HENRIETTA RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1355
Mailing Address - Country:US
Mailing Address - Phone:585-272-0120
Mailing Address - Fax:585-272-0123
Practice Address - Street 1:2024 W HENRIETTA RD
Practice Address - Street 2:SUITE C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1355
Practice Address - Country:US
Practice Address - Phone:585-272-0120
Practice Address - Fax:585-272-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041406-011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty