Peter John Demarco Jr., DDS
Individual provider Active NPI Dentist · Eden, NY
NPI 1922095355 · NPPES record last updated May 28, 2014
Key facts
- NPI
- 1922095355
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 040945 (NY)
- Practice address
- 3122 Kulp Rd.
Eden, NY 14057 - Phone
- (716) 575-4108
- NPI assigned
- Sep 30, 2005
- Reactivated
- May 28, 2014
- Sex
- Male
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in NY
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20120820000808 | NY | Order and Referring Only - Dentist |
4183871593 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 040945 | NY | Yes |
Addresses
Primary practice location
3122 Kulp Rd.
Eden, NY 14057
Mailing address
3122 Kulp Rd.
Eden, NY 14057
Phone (716) 575-4108
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 01095514 | Medicaid | NY |
Other providers in Eden, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 28, 2014. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.