Provider Demographics
NPI:1730403924
Name:NORTH TONAWANDA FAMILY DENTISTRY PC
Entity type:Organization
Organization Name:NORTH TONAWANDA FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PATIENT CARE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:VACANTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-692-2273
Mailing Address - Street 1:301 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2819
Mailing Address - Country:US
Mailing Address - Phone:716-692-2273
Mailing Address - Fax:716-692-2211
Practice Address - Street 1:301 MEADOW DR
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-2819
Practice Address - Country:US
Practice Address - Phone:716-692-2273
Practice Address - Fax:716-692-2211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0573661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03217594Medicaid