Provider Demographics
NPI:1275215121
Name:DYSERT, ANDREA BERNADETTE (RDH)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:BERNADETTE
Last Name:DYSERT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:BERNADETTE
Other - Last Name:WAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:155 LAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14207-1816
Mailing Address - Country:US
Mailing Address - Phone:716-875-2904
Mailing Address - Fax:716-875-6717
Practice Address - Street 1:155 LAWN AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14207-1816
Practice Address - Country:US
Practice Address - Phone:716-875-2904
Practice Address - Fax:716-875-6717
Is Sole Proprietor?:No
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028591124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist