MEDICARE: DR. PHANITH LEANG LIM D.D.S.

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	1223G0001X	General Practice Dentistry	053216-1	NY

General Provider Information

NPI Number	:	1558561308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHANITH LEANG LIM D.D.S.

Provider Business Mailing Address
First Line	:	271 PALMDALE DR APT 3
Second Line	:
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-4013
Country	:	US
Telephone Number	:	571-276-5045
Fax Number	:

Provider Business Practice Location Address
First Line	:	9290 BOSTON STATE RD
Second Line	:
City	:	BOSTON
State	:	NY
Zip	:	14025-9604
Country	:	US
Telephone Number	:	716-941-5352
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2007
Last Update Date	:	09/28/2007

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