Provider Demographics
NPI:1649389560
Name:UNIVERSITY PEDIATRIC DENTISTRY, P.C.
Entity type:Organization
Organization Name:UNIVERSITY PEDIATRIC DENTISTRY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCANULTY
Authorized Official - Suffix:
Authorized Official - Credentials:MSA
Authorized Official - Phone:716-688-7712
Mailing Address - Street 1:1100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-2308
Mailing Address - Country:US
Mailing Address - Phone:716-242-8200
Mailing Address - Fax:
Practice Address - Street 1:1100 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222
Practice Address - Country:US
Practice Address - Phone:716-242-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01181424Medicaid
NY03376083Medicaid