MEDICARE: BROOKSIDE DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0400251	NY

General Provider Information

NPI Number	:	1043550098
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROOKSIDE DENTAL LLC

Provider Business Mailing Address
First Line	:	9736 TRANSIT RD
Second Line	:	SUITE B
City	:	EAST AMHERST
State	:	NY
Zip	:	14051-1311
Country	:	US
Telephone Number	:	716-688-0091
Fax Number	:

Provider Business Practice Location Address
First Line	:	9736 TRANSIT RD
Second Line	:	SUITE B
City	:	EAST AMHERST
State	:	NY
Zip	:	14051-1311
Country	:	US
Telephone Number	:	716-688-0091
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHRISTINE GUARDINO
Credential	:	DMD
Telephone Number	:	716-688-0091

Provider Enumeration Date	:	02/27/2013
Last Update Date	:	02/27/2013

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