MEDICARE: TSA DENTAL PC

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	046843-1	NY
2	122300000X	Dentist	055792	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386197358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TSA DENTAL PC

Provider Business Mailing Address
First Line	:	7210 NORTH FOREST ROAD
Second Line	:
City	:	GETZVILLE
State	:	NY
Zip	:	14068
Country	:	US
Telephone Number	:	716-707-3334
Fax Number	:	716-707-3334

Provider Business Practice Location Address
First Line	:	7210 NORTH FOREST ROAD
Second Line	:
City	:	AMHERST
State	:	NY
Zip	:	14068
Country	:	US
Telephone Number	:	716-707-3334
Fax Number	:	716-707-3334

Authorized Official
Title or Position	:	OWNER,CEO
Name	:	DR. ROBERT J LACARRUBBA
Credential	:
Telephone Number	:	716-390-8185

Provider Enumeration Date	:	07/26/2016
Last Update Date	:	07/26/2016

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Directions to “TSA DENTAL PC ” Practice Location

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