Provider Demographics
NPI:1326394404
Name:NIAGARA FAMILY DENTAL, P.C.
Entity type:Organization
Organization Name:NIAGARA FAMILY DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-883-3664
Mailing Address - Street 1:821 NIAGARA ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14213-2420
Mailing Address - Country:US
Mailing Address - Phone:716-883-3664
Mailing Address - Fax:716-883-0202
Practice Address - Street 1:821 NIAGARA ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14213-2420
Practice Address - Country:US
Practice Address - Phone:716-883-3664
Practice Address - Fax:716-883-0202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0444961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01388852Medicaid