MEDICARE: BOSTON 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	122300000X	Dentist	32221	NY

General Provider Information

NPI Number	:	1265737571
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOSTON DENTAL LLC

Provider Business Mailing Address
First Line	:	8397 BOSTON STATE RD
Second Line	:
City	:	BOSTON
State	:	NY
Zip	:	14025-9651
Country	:	US
Telephone Number	:	716-941-5433
Fax Number	:

Provider Business Practice Location Address
First Line	:	8397 BOSTON STATE RD
Second Line	:
City	:	BOSTON
State	:	NY
Zip	:	14025-9651
Country	:	US
Telephone Number	:	716-941-5433
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHARLES ALAN MATLACH
Credential	:	D.D.S.
Telephone Number	:	716-941-5433

Provider Enumeration Date	:	01/18/2011
Last Update Date	:	01/18/2011

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Directions to “BOSTON DENTAL LLC ” Practice Location

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