Brewerton Family Dentistry

Primary specialty

DentistTaxonomy code 122300000X

License

051614 Issued in NY

Legal business name

BREWERTON FAMILY DENTISTRY

Practice address

5501 Bartel Rd
Brewerton, NY 13029-8701

Phone

(315) 676-2209

Fax

(315) 676-2247

NPI assigned

Mar 9, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Imadeh R Nosegbe, DMD

Title

Owner

Phone

(315) 676-2209

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173398400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1164553079",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 830",
            "city": "BREWERTON",
            "state": "NY",
            "postal_code": "130290830",
            "telephone_number": "315-676-2209",
            "fax_number": "315-676-2247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5501 BARTEL RD",
            "city": "BREWERTON",
            "state": "NY",
            "postal_code": "130298701",
            "telephone_number": "315-676-2209",
            "fax_number": "315-676-2247"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BREWERTON FAMILY DENTISTRY",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-09",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "NOSEGBE",
        "authorized_official_first_name": "IMADEH",
        "authorized_official_middle_name": "R",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "315-676-2209",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NY",
            "license": "051614",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "02570547",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Brett R Bunker, P.A.
• Jason Vincent Calcara, MS, OTR/L
• Thomas Mark Carroll, DDS

• Dentist in Brewerton, NY
• Providers in Brewerton, NY by specialty
• Dentist in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.