Healthcare Provider Details

I. General information

NPI: 1669513842
Provider Name (Legal Business Name): ROBERT MOYNIHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8397 BOSTON STATE RD
BOSTON NY
14025-9651
US

IV. Provider business mailing address

8397 BOSTON STATE RD
BOSTON NY
14025-9651
US

V. Phone/Fax

Practice location:
  • Phone: 716-941-5433
  • Fax:
Mailing address:
  • Phone: 716-864-5488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049925
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: