Provider Demographics
NPI:1871294116
Name:CLOVER LEAF DENTAL PLLC
Entity type:Organization
Organization Name:CLOVER LEAF DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SZCZUPAKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-913-4274
Mailing Address - Street 1:59 ELIZABETH DR
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5226
Mailing Address - Country:US
Mailing Address - Phone:716-433-8332
Mailing Address - Fax:
Practice Address - Street 1:59 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5226
Practice Address - Country:US
Practice Address - Phone:716-433-8332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental