Provider Demographics
NPI:1205172236
Name:BUFFALO DENTAL GROUP, LLC
Entity type:Organization
Organization Name:BUFFALO DENTAL GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:LEPOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-515-8022
Mailing Address - Street 1:12528 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-6000
Mailing Address - Country:US
Mailing Address - Phone:713-333-8500
Mailing Address - Fax:713-333-8501
Practice Address - Street 1:12528 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-6000
Practice Address - Country:US
Practice Address - Phone:713-333-8500
Practice Address - Fax:713-333-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX228531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty