Provider Demographics
NPI:1124408364
Name:LAKE CHUTUAQUA DENTAL, PC
Entity Type:Organization
Organization Name:LAKE CHUTUAQUA DENTAL, PC
Other - Org Name:MONDOVI DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CATLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-763-9838
Mailing Address - Street 1:70 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-1812
Mailing Address - Country:US
Mailing Address - Phone:716-763-9838
Mailing Address - Fax:
Practice Address - Street 1:70 E FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NY
Practice Address - Zip Code:14750-1812
Practice Address - Country:US
Practice Address - Phone:716-763-9838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty