Basic Information
| Provider Information | |||||||||
| NPI: | 1902077928 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KENMORE QUALITYCARE DENTISTRY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 956 KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142161450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168747112 | ||||||||
| FaxNumber: | 7168747113 | ||||||||
| Practice Location | |||||||||
| Address1: | 956 KENMORE AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142161450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168747112 | ||||||||
| FaxNumber: | 7168747113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2008 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | LACARRUBBA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7162975500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | NY | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | GRP529003001 | 01 | NY | BC/BS CHILD HEALTH PLUS | OTHER |