Provider Demographics
NPI:1154482818
Name:LOCKPORT DENTAL GROUP, P.C.
Entity Type:Organization
Organization Name:LOCKPORT DENTAL GROUP, P.C.
Other - Org Name:LDG SLEEP ACADEMY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:RETELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-433-6004
Mailing Address - Street 1:39 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5226
Mailing Address - Country:US
Mailing Address - Phone:716-433-6004
Mailing Address - Fax:716-433-7547
Practice Address - Street 1:39 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5226
Practice Address - Country:US
Practice Address - Phone:716-433-6004
Practice Address - Fax:716-433-7547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
NY041617332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty