Provider Demographics
NPI:1114015237
Name:COPPERTHITE, DAWN RENEE (RD,CDN)
Entity type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:RENEE
Last Name:COPPERTHITE
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:RENEE
Other - Last Name:BUNGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDN
Mailing Address - Street 1:5666 KECK RD
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-9307
Mailing Address - Country:US
Mailing Address - Phone:716-228-8163
Mailing Address - Fax:716-626-3416
Practice Address - Street 1:300 INTERNATIONAL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5781
Practice Address - Country:US
Practice Address - Phone:716-228-8163
Practice Address - Fax:716-626-3416
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001213-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026589601OtherUNIVERA HEALTHCARE #
NY65-10942OtherINDEPENDENT HEALTH #
NYJ300238909OtherCMSMED