Provider Demographics
NPI:1780733964
Name:PEREZ, PETER C (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:C
Last Name:PEREZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779-1104
Mailing Address - Country:US
Mailing Address - Phone:716-945-3686
Mailing Address - Fax:
Practice Address - Street 1:288 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779-1104
Practice Address - Country:US
Practice Address - Phone:716-945-3686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00639932Medicaid