=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477741635
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTAL CARE, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2007
-----------------------------------------------------
Last Update Date | 10/11/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13 HOPKINS RD
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-4641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-633-1991
-----------------------------------------------------
Fax | 716-633-2435
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13 HOPKINS RD
-----------------------------------------------------
City | WILLIAMSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14221-4641
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-633-1991
-----------------------------------------------------
Fax | 716-633-2435
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JENNIFER LEE COMPO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 716-633-1991
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 036938
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------