Provider Demographics
NPI:1740494137
Name:PORTVILLE DENTAL PLLC
Entity type:Organization
Organization Name:PORTVILLE DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLIN
Authorized Official - Middle Name:BOYCE
Authorized Official - Last Name:MCDIVITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-933-6787
Mailing Address - Street 1:149 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14770-9703
Mailing Address - Country:US
Mailing Address - Phone:716-933-6787
Mailing Address - Fax:716-933-0117
Practice Address - Street 1:149 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14770-9703
Practice Address - Country:US
Practice Address - Phone:716-933-6787
Practice Address - Fax:716-933-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1223G0001X1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005536000001Medicaid
1962490987OtherMCDIVITT NPI
NY02386001NYMedicaid
1407844426OtherPETRYSZAK NPI
NY00605445NYMedicaid
007700991OtherMCDIVITT BC BS