Provider Demographics
NPI:1700109162
Name:WESTERN NEW YORK DENTAL GROUP, P.C.
Entity type:Organization
Organization Name:WESTERN NEW YORK DENTAL GROUP, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5699
Mailing Address - Street 1:5007 TRANSIT RD
Mailing Address - Street 2:
Mailing Address - City:DEPEW
Mailing Address - State:NY
Mailing Address - Zip Code:14043-4617
Mailing Address - Country:US
Mailing Address - Phone:716-652-7080
Mailing Address - Fax:716-206-0895
Practice Address - Street 1:5007 TRANSIT RD
Practice Address - Street 2:
Practice Address - City:DEPEW
Practice Address - State:NY
Practice Address - Zip Code:14043-4617
Practice Address - Country:US
Practice Address - Phone:716-652-7080
Practice Address - Fax:716-206-0895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-12
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047869122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty