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General NPI Number Information
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NPI Number | 1194911693
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Entity Type | Organization
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Legal Business Name | RICHARD ETENGOFF DDS PC
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 09/18/2007
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Provider Practice Location Address
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Address Line | 1241 COLVIN AVE
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City | BUFFALO
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State | NY
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Zip | 14223
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Country | US
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Telephone | 716-877-5941
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Fax | 716-877-8409
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Provider Business Mailing Address
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Address Line | 1241 COLVIN AVE
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City | BUFFALO
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State | NY
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Zip | 14223
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Country | US
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Telephone | 716-877-5941
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Fax | 716-877-8409
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Authorized Official
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Title or Position | PRESIDENT ORTHODONTIST
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Name | DR. RICHARD ALAN ETENGOFF
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Credential | DDS
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Telephone | 716-877-5941
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 0320981
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License Number State | NY
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