Healthcare Provider Details

I. General information

NPI: 1053369983
Provider Name (Legal Business Name): J NICHOLAS PORCELLO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 12/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LIONEL R. JOHN HEALTH CENTER 987 RC HOAG DR
SALAMANCA NY
14779
US

IV. Provider business mailing address

LIONEL R. JOHN HEALTH CENTER 987 RC HOAG DR
SALAMANCA NY
14779
US

V. Phone/Fax

Practice location:
  • Phone: 716-945-5894
  • Fax: 716-945-5889
Mailing address:
  • Phone: 716-945-5894
  • Fax: 716-945-5889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number051311
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: