Healthcare Provider Details

I. General information

NPI: 1578514329
Provider Name (Legal Business Name): PETER MAKULA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

USA DENTAC, APG DENTAL CLINIC FORT MEADE CREDENTIALS OFFICE
FORT MEADE MD
20755-5700
US

IV. Provider business mailing address

300 WEST AVE
BROCKPORT NY
14420-1118
US

V. Phone/Fax

Practice location:
  • Phone: 301-677-5922
  • Fax: 301-677-5710
Mailing address:
  • Phone: 585-637-3905
  • Fax: 585-637-4990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number051425
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: