Healthcare Provider Details

I. General information

NPI: 1124133699
Provider Name (Legal Business Name): ALFONSE J GAMBACORTA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 MICHIGAN AVE
BUFFALO NY
14203-2209
US

IV. Provider business mailing address

425 MICHIGAN AVE
BUFFALO NY
14203-2209
US

V. Phone/Fax

Practice location:
  • Phone: 716-828-8308
  • Fax: 716-828-8307
Mailing address:
  • Phone: 716-828-8308
  • Fax: 716-828-8307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number047542-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: