Healthcare Provider Details

I. General information

NPI: 1366532194
Provider Name (Legal Business Name): PETER TIMOTHY BLISS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 05/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 MAIN ST
OLEAN NY
14760-1532
US

IV. Provider business mailing address

623 MAIN ST
OLEAN NY
14760-1532
US

V. Phone/Fax

Practice location:
  • Phone: 716-375-7306
  • Fax: 716-375-7463
Mailing address:
  • Phone: 716-375-7306
  • Fax: 716-375-7463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD16672
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number056537
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: