Healthcare Provider Details

I. General information

NPI: 1821007691
Provider Name (Legal Business Name): WNY TMD & OROFACIAL PAIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4134 SENECA ST
WEST SENECA NY
14224-3044
US

IV. Provider business mailing address

4134 SENECA ST
WEST SENECA NY
14224-3044
US

V. Phone/Fax

Practice location:
  • Phone: 716-675-5858
  • Fax: 716-675-4872
Mailing address:
  • Phone: 716-675-5858
  • Fax: 716-675-4872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number028517
License Number StateNY

VIII. Authorized Official

Name: DR. ROBERT STEPHEN KULL
Title or Position: PRESIDENT
Credential: D. D. S. M. S.
Phone: 716-675-5858