=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154703288
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN ORTHODONTICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2015
-----------------------------------------------------
Last Update Date | 06/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3040 AMSDELL RD
-----------------------------------------------------
City | HAMBURG
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14075-5835
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-534-1460
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 495 DELAWARE ST
-----------------------------------------------------
City | TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14150-5348
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-693-9077
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MS. CATHY LOUISE RUCHLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-693-9077
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 054753
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 052405
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------