=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871735894
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICHOLAS JOSEPH SCHELLATI JR. M.D., D.D.S
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2009
-----------------------------------------------------
Last Update Date | 07/25/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6534 ANTHONY DR SUITE A
-----------------------------------------------------
City | VICTOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14564-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-924-3612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6534 ANTHONY DR SUITE A
-----------------------------------------------------
City | VICTOR
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14564-1403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-924-3612
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 052737
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------