Healthcare Provider Details

I. General information

NPI: 1457873473
Provider Name (Legal Business Name): MARTIN CHOCHOLIK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9864 LUCKEY DR
HOUGHTON NY
14744-8706
US

IV. Provider business mailing address

9864 LUCKEY DR
HOUGHTON NY
14744-8706
US

V. Phone/Fax

Practice location:
  • Phone: 716-375-7500
  • Fax:
Mailing address:
  • Phone: 716-375-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1001927-15
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number060146-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: