Healthcare Provider Details

I. General information

NPI: 1881675726
Provider Name (Legal Business Name): JOHN LLEWELLYN HOUGHTALING DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 DELAWARE AVE
BUFFALO NY
14209-1603
US

IV. Provider business mailing address

19 BONDCROFT DR
AMHERST NY
14226-3424
US

V. Phone/Fax

Practice location:
  • Phone: 716-885-0510
  • Fax:
Mailing address:
  • Phone: 716-885-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number029731
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: