Provider Demographics
NPI:1275794950
Name:GREAT LAKES DENTISTRY
Entity Type:Organization
Organization Name:GREAT LAKES DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:RAPPOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-668-9700
Mailing Address - Street 1:20 LOSSON RD STE 110
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-2379
Mailing Address - Country:US
Mailing Address - Phone:716-668-9700
Mailing Address - Fax:716-668-9702
Practice Address - Street 1:20 LOSSON RD STE 110
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-2379
Practice Address - Country:US
Practice Address - Phone:716-668-9700
Practice Address - Fax:716-668-9702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051753122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty