=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568982049
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MACDONALD TYSKA & ALEXANDER ORTHODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2017
-----------------------------------------------------
Last Update Date | 06/26/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1077 DELAWARE RD
-----------------------------------------------------
City | TONAWANDA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14223-1056
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-875-0405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9650 MAIN ST
-----------------------------------------------------
City | CLARENCE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14031-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANDREW L MACDONALD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 716-759-8323
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 042239
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------