1508067059 NPI number — TRI-COUNTY DENTAL, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508067059 NPI number — TRI-COUNTY DENTAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-COUNTY DENTAL, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508067059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALAMANCA
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14779-1529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-945-7500
Provider Business Mailing Address Fax Number:
716-945-7774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALAMANCA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14779-1529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-945-7500
Provider Business Practice Location Address Fax Number:
716-945-7774
Provider Enumeration Date:
05/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CULVER
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
716-945-7500

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  043623-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02848864 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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