NPIMap

Organization Active NPI

Green Lakes Dental, LLP

  • Dental Clinic/Center
  • Fayetteville, NY
National Provider Identifier
1174259212
Registry record updated Jul 30, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
Legal business name
GREEN LAKES DENTAL, LLP
Practice address
511 E Genesee St
Fayetteville, NY 13066-1524
Phone
(315) 637-4616
NPI assigned
Jul 30, 2022
Last updated
Jul 30, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 30, 2022

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

Authorized official

Name
Dr. Tyler MaxwellNPI 1396273298
Title
Owner
Phone
(315) 637-4616

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X Primary

Addresses

Primary practice location

511 E Genesee St
Fayetteville, NY 13066-1524

Mailing address

511 E Genesee St
Fayetteville, NY 13066-1524
Phone (585) 469-8545

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1659139200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1659139200000",
    "number": "1174259212",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "511 E GENESEE ST",
            "city": "FAYETTEVILLE",
            "state": "NY",
            "postal_code": "130661524",
            "telephone_number": "585-469-8545"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "511 E GENESEE ST",
            "city": "FAYETTEVILLE",
            "state": "NY",
            "postal_code": "130661524",
            "telephone_number": "315-637-4616"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GREEN LAKES DENTAL, LLP",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-07-30",
        "last_updated": "2022-07-30",
        "certification_date": "2022-07-30",
        "status": "A",
        "authorized_official_last_name": "MAXWELL",
        "authorized_official_first_name": "TYLER",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "315-637-4616",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fayetteville, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 30, 2022; 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.