Provider Demographics
NPI:1215055314
Name:PARK DENTAL ASSOCIATES, PLLC
Entity type:Organization
Organization Name:PARK DENTAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:POLEON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-909-1470
Mailing Address - Street 1:90 GROTON DR APT 4
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2547
Mailing Address - Country:US
Mailing Address - Phone:716-909-1470
Mailing Address - Fax:
Practice Address - Street 1:880 WESTFALL RD
Practice Address - Street 2:SUITE C
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2611
Practice Address - Country:US
Practice Address - Phone:716-909-1470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050613-11223G0001X
NY053052-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty