MEDICARE: GREAT LAKES DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	051753	NY

General Provider Information

NPI Number	:	1275794950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES DENTISTRY

Provider Business Mailing Address
First Line	:	20 LOSSON RD STE 110
Second Line	:
City	:	CHEEKTOWAGA
State	:	NY
Zip	:	14227-2379
Country	:	US
Telephone Number	:	716-668-9700
Fax Number	:	716-668-9702

Provider Business Practice Location Address
First Line	:	20 LOSSON RD STE 110
Second Line	:
City	:	CHEEKTOWAGA
State	:	NY
Zip	:	14227-2379
Country	:	US
Telephone Number	:	716-668-9700
Fax Number	:	716-668-9702

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. AMY LYNN RAPPOLD
Credential	:	D.D.S.
Telephone Number	:	716-668-9700

Provider Enumeration Date	:	06/24/2008
Last Update Date	:	06/24/2008

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Directions to “GREAT LAKES DENTISTRY ” Practice Location

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