Healthcare Provider Details

I. General information

NPI: 1720484165
Provider Name (Legal Business Name): JACQUELINE SZCZUPAKOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 EGGERT RD
AMHERST NY
14226-2139
US

IV. Provider business mailing address

246 SUNDOWN TRL
WILLIAMSVILLE NY
14221-2202
US

V. Phone/Fax

Practice location:
  • Phone: 716-838-3838
  • Fax: 716-838-3838
Mailing address:
  • Phone: 716-913-4274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number058433
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: