Provider Demographics
NPI:1407502537
Name:BUFFALO ROAD DENTAL LLC
Entity Type:Organization
Organization Name:BUFFALO ROAD DENTAL LLC
Other - Org Name:HARBORCREEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:VICENTA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:PO BOX 734753
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4753
Mailing Address - Country:US
Mailing Address - Phone:814-899-0444
Mailing Address - Fax:814-898-2403
Practice Address - Street 1:4820 BUFFALO RD
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-2302
Practice Address - Country:US
Practice Address - Phone:814-899-0444
Practice Address - Fax:814-898-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-28
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty