Provider Demographics
NPI:1689710204
Name:WILLIAMSVILLE DENTAL GROUP
Entity Type:Organization
Organization Name:WILLIAMSVILLE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:ELY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-633-1187
Mailing Address - Street 1:40 N UNION RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-633-1187
Mailing Address - Fax:716-633-4276
Practice Address - Street 1:40 N UNION RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221
Practice Address - Country:US
Practice Address - Phone:716-633-1187
Practice Address - Fax:716-633-4276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0283111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02666475Medicaid