=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265421200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETER D. PURCELL DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2005
-----------------------------------------------------
Last Update Date | 09/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 POTTERS RD
-----------------------------------------------------
City | WEST SENECA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14220-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-822-2499
-----------------------------------------------------
Fax | 716-821-9672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 POTTERS RD
-----------------------------------------------------
City | WEST SENECA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14220-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-822-2499
-----------------------------------------------------
Fax | 716-821-9672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 38389
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 1223X0400X
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------