MEDICARE: WNY TMD & OROFACIAL PAIN

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	1744P3200X	Prosthetics Case Management	028517	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4001292	OTHER	NY	INDEPENDENT HEALTH INS

General Provider Information

NPI Number	:	1821007691
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WNY TMD & OROFACIAL PAIN

Provider Business Mailing Address
First Line	:	4134 SENECA ST
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14224-3044
Country	:	US
Telephone Number	:	716-675-5858
Fax Number	:	716-675-4872

Provider Business Practice Location Address
First Line	:	4134 SENECA ST
Second Line	:
City	:	WEST SENECA
State	:	NY
Zip	:	14224-3044
Country	:	US
Telephone Number	:	716-675-5858
Fax Number	:	716-675-4872

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ROBERT STEPHEN KULL
Credential	:	D. D. S. M. S.
Telephone Number	:	716-675-5858

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	08/22/2020

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