Provider Demographics
NPI:1659032639
Name:ELMWOOD VILLAGE DENTAL PC
Entity Type:Organization
Organization Name:ELMWOOD VILLAGE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING LIAISON
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-646-9423
Mailing Address - Street 1:2707 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14150-9466
Mailing Address - Country:US
Mailing Address - Phone:716-646-9423
Mailing Address - Fax:716-557-7225
Practice Address - Street 1:892 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-1494
Practice Address - Country:US
Practice Address - Phone:716-332-0460
Practice Address - Fax:716-881-0449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1235378803OtherINDIVIDUAL NPI
NY1467915165OtherINDIVIDUAL NPI
NY1831727882OtherINDIVIDUAL NPI
NY1942677539OtherINDIVIDUAL NPI
NY1417334293OtherINDIVIDUAL NPI
NY1295767598OtherINDIVIDUAL NPI
NY1124581251OtherINDIVIDUAL NPI
NY1154781326OtherINDIVIDUAL NPI
NY1356918080OtherINDIVIDUAL NPI
NY1447338686OtherINDIVIDUAL NPI
NY1720471063OtherINDIVIDUAL NPI