Healthcare Provider Details

I. General information

NPI: 1457072126
Provider Name (Legal Business Name): GRIGORIOS LAVRENTIADIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 SQUIRE HALL
BUFFALO NY
14214-8006
US

IV. Provider business mailing address

215 SQUIRE HALL
BUFFALO NY
14214-8006
US

V. Phone/Fax

Practice location:
  • Phone: 716-645-8131
  • Fax:
Mailing address:
  • Phone: 716-645-8131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number000141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: