Provider Demographics
NPI:1053369983
Name:PORCELLO, J NICHOLAS (DDS)
Entity type:Individual
Prefix:
First Name:J
Middle Name:NICHOLAS
Last Name:PORCELLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LIONEL R. JOHN HEALTH CENTER
Mailing Address - Street 2:987 RC HOAG DR
Mailing Address - City:SALAMANCA
Mailing Address - State:NY
Mailing Address - Zip Code:14779
Mailing Address - Country:US
Mailing Address - Phone:716-945-5894
Mailing Address - Fax:716-945-5889
Practice Address - Street 1:LIONEL R. JOHN HEALTH CENTER
Practice Address - Street 2:987 RC HOAG DR
Practice Address - City:SALAMANCA
Practice Address - State:NY
Practice Address - Zip Code:14779
Practice Address - Country:US
Practice Address - Phone:716-945-5894
Practice Address - Fax:716-945-5889
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051311122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000527781001OtherBC/BS OF WNY
NY00001783898OtherUNITED CONCORDIA
NY00025887504OtherUNIVERA/HEALTHPLEX