Healthcare Provider Details

I. General information

NPI: 1821322249
Provider Name (Legal Business Name): MICHAEL LEO DOMBOSKI D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2009
Last Update Date: 10/01/2009
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: 716-375-7300
  • Fax:
Mailing address:
  • Phone: 716-375-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number033853-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: