=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083824981
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANFORD HARRIS EISEN DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2880 SENECA ST
-----------------------------------------------------
City | WEST SENECA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14224-1863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-822-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 81 GREENAWAY RD
-----------------------------------------------------
City | AMHERST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14226-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-832-2711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | NY29401
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------