Provider Demographics
NPI:1255426805
Name:THE SUMMIT DENTAL GROUP, PC
Entity type:Organization
Organization Name:THE SUMMIT DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:315-457-0620
Mailing Address - Street 1:PO BOX 2645
Mailing Address - Street 2:7555 MORGAN ROAD
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13089
Mailing Address - Country:US
Mailing Address - Phone:315-457-0620
Mailing Address - Fax:315-457-0656
Practice Address - Street 1:7555 MORGAN ROAD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13089
Practice Address - Country:US
Practice Address - Phone:315-457-0620
Practice Address - Fax:315-457-0656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty