Provider Demographics
NPI:1922095355
Name:DEMARCO, PETER JOHN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:JOHN
Last Name:DEMARCO
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3122 KULP RD.
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14057
Mailing Address - Country:US
Mailing Address - Phone:716-575-4108
Mailing Address - Fax:
Practice Address - Street 1:3122 KULP RD.
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NY
Practice Address - Zip Code:14057
Practice Address - Country:US
Practice Address - Phone:716-575-4108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2014-05-28
Deactivation Date:2014-05-14
Deactivation Code:
Reactivation Date:2014-05-28
Provider Licenses
StateLicense IDTaxonomies
NY040945122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01095514Medicaid
U39662Medicare UPIN