Provider Demographics
NPI:1366532194
Name:BLISS, PETER TIMOTHY (DMD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:TIMOTHY
Last Name:BLISS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1532
Mailing Address - Country:US
Mailing Address - Phone:716-375-7306
Mailing Address - Fax:716-375-7463
Practice Address - Street 1:623 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1532
Practice Address - Country:US
Practice Address - Phone:716-375-7306
Practice Address - Fax:716-375-7463
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID166721223S0112X
NY0565371223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM15690Medicare ID - Type Unspecified
MIU58058Medicare UPIN