Healthcare Provider Details

I. General information

NPI: 1750494050
Provider Name (Legal Business Name): ORTHODONTISTS ASSOCIATES OF WESTERN NEW YORK, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 N 3RD ST
OLEAN NY
14760-2504
US

IV. Provider business mailing address

138 N 3RD ST
OLEAN NY
14760-2504
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-8017
  • Fax:
Mailing address:
  • Phone: 716-372-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number041550
License Number StateNY

VIII. Authorized Official

Name: DR. DOMINIC A COLARUSSO JR.
Title or Position: PRESIDENT
Credential: DDS
Phone: 716-372-8017