Healthcare Provider Details

I. General information

NPI: 1194739144
Provider Name (Legal Business Name): PETER R KOWALSKI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 RIDGE RD
LACKAWANNA NY
14218-1818
US

IV. Provider business mailing address

200 MARTIN AVE
BLASDELL NY
14219-1548
US

V. Phone/Fax

Practice location:
  • Phone: 716-823-4455
  • Fax:
Mailing address:
  • Phone: 716-823-5650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number043098
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: