Provider Demographics
NPI:1508067059
Name:TRI-COUNTY DENTAL, PC
Entity Type:Organization
Organization Name:TRI-COUNTY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:CULVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-945-7500
Mailing Address - Street 1:117 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1529
Mailing Address - Country:US
Mailing Address - Phone:716-945-7500
Mailing Address - Fax:716-945-7774
Practice Address - Street 1:117 MAIN ST
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1529
Practice Address - Country:US
Practice Address - Phone:716-945-7500
Practice Address - Fax:716-945-7774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043623-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02848864Medicaid
NY=========OtherTIN