Healthcare Provider Details

I. General information

NPI: 1821225236
Provider Name (Legal Business Name): DR. PHILIP VINCENT VULLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 09/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5845 MAIN ST
WILLIAMSVILLE NY
14221-5709
US

IV. Provider business mailing address

170 RANCH TRL
WILLIAMSVILLE NY
14221-2439
US

V. Phone/Fax

Practice location:
  • Phone: 716-634-1234
  • Fax:
Mailing address:
  • Phone: 716-688-8651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number23403
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: