Provider Demographics
NPI:1275633273
Name:UNIVERSITY DENTAL ASSOCIATES, INC.
Entity Type:Organization
Organization Name:UNIVERSITY DENTAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:F
Authorized Official - Last Name:ORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-829-6370
Mailing Address - Street 1:210A SQUIRE HALL
Mailing Address - Street 2:SCHOOL OF DENTAL MEDICINE UNIVERSITY AT BUFFALO SUNY
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-8006
Mailing Address - Country:US
Mailing Address - Phone:716-829-2721
Mailing Address - Fax:
Practice Address - Street 1:210A SQUIRE HALL
Practice Address - Street 2:SCHOOL OF DENTAL MEDICINE UNIVERSITY AT BUFFALO SUNY
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214-8006
Practice Address - Country:US
Practice Address - Phone:716-829-2721
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY13022AMedicare PIN