Basic Information
Provider Information | |||||||||
NPI: | 1447578737 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARL | ||||||||
FirstName: | CHAYA | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SISKIND | ||||||||
OtherFirstName: | CHAYA | ||||||||
OtherMiddleName: | P | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 89 GENESEE ST | ||||||||
Address2: | HEALTHREACH | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146113201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5853683720 | ||||||||
FaxNumber: | 5853683723 | ||||||||
Practice Location | |||||||||
Address1: | 89 GENESEE ST | ||||||||
Address2: | HEALTHREACH | ||||||||
City: | ROCHESTER | ||||||||
State: | NY | ||||||||
PostalCode: | 146113201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5853683720 | ||||||||
FaxNumber: | 5853683723 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2010 | ||||||||
LastUpdateDate: | 01/22/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 055492 | NY | Y |   | Dental Providers | Dentist | General Practice |
ID Information
ID | Type | State | Issuer | Description | 03387657 | 05 | NY |   | MEDICAID |