Provider Demographics
NPI:1144730649
Name:PEDIATRIC DENTAL ASSOCIATES PLLC
Entity type:Organization
Organization Name:PEDIATRIC DENTAL ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CREIGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-688-7712
Mailing Address - Street 1:1800 MAPLE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2749
Mailing Address - Country:US
Mailing Address - Phone:716-688-7712
Mailing Address - Fax:
Practice Address - Street 1:1800 MAPLE RD STE 200
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2749
Practice Address - Country:US
Practice Address - Phone:716-688-7712
Practice Address - Fax:716-688-4719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0579711223G0001X
NY310861223P0221X
NY0457621223P0221X
NY0584381223P0700X
NY0509461223S0112X
NY0405791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty