MEDICARE: DR. MARSHALL DARYL FAGIN DDS

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	1223P0700X	Prosthodontics	030795	NY

General Provider Information

NPI Number	:	1114948510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARSHALL DARYL FAGIN DDS

Provider Business Mailing Address
First Line	:	6471 TRANSIT RD
Second Line	:	SUITE #1
City	:	EAST AMHERST
State	:	NY
Zip	:	14051-1427
Country	:	US
Telephone Number	:	716-633-7070
Fax Number	:	716-689-6327

Provider Business Practice Location Address
First Line	:	6471 TRANSIT RD
Second Line	:	SUITE #1
City	:	EAST AMHERST
State	:	NY
Zip	:	14051-1427
Country	:	US
Telephone Number	:	716-633-7070
Fax Number	:	716-689-6327

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	10/23/2012

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