Healthcare Provider Details

I. General information

NPI: 1154619302
Provider Name (Legal Business Name): ELIZABETH HARGRAVE D'ANGELO D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2011
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SQUIRE HALL
BUFFALO NY
14214-8006
US

IV. Provider business mailing address

140 ALEXANDER WAY
ORCHARD PARK NY
14127-4450
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-2862
  • Fax:
Mailing address:
  • Phone: 716-713-8885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number056347-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: