Healthcare Provider Details

I. General information

NPI: 1063852432
Provider Name (Legal Business Name): JOSE LUIS TAPIA D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2013
Last Update Date: 07/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 MAIN ST 355 SQUIRE HALL, UNIVERSITY AT BUFFALO
BUFFALO NY
14214-3001
US

IV. Provider business mailing address

3435 MAIN ST 355 SQUIRE HALL, UNIVERSITY AT BUFFALO
BUFFALO NY
14214-3001
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-2538
  • Fax:
Mailing address:
  • Phone: 716-829-2538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number056546-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: