Healthcare Provider Details

I. General information

NPI: 1003450735
Provider Name (Legal Business Name): SUBURBAN DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 ABBOTT ROAD
BUFFALO NY
14220
US

IV. Provider business mailing address

1050 ABBOTT ROAD
BUFFALO NY
14220
US

V. Phone/Fax

Practice location:
  • Phone: 716-649-5254
  • Fax: 716-822-0592
Mailing address:
  • Phone: 716-649-5254
  • Fax: 716-822-0592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JASON JONES
Title or Position: OWNER
Credential: DDS
Phone: 716-649-5254