Healthcare Provider Details

I. General information

NPI: 1669410015
Provider Name (Legal Business Name): MARK L TWICHELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 WEST MAIN ST
FREDONIA NY
14063
US

IV. Provider business mailing address

85 WEST MAIN ST
FREDONIA NY
14063
US

V. Phone/Fax

Practice location:
  • Phone: 716-672-2854
  • Fax: 716-672-5269
Mailing address:
  • Phone: 716-672-2854
  • Fax: 716-672-5269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number032849
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: