Provider Demographics
NPI:1073631156
Name:MATTIACIO, MICHAEL DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:MATTIACIO
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 1:2946 ERIE BLVD E
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1431
Mailing Address - Country:US
Mailing Address - Phone:315-445-2678
Mailing Address - Fax:315-445-2838
Practice Address - Street 1:2946 ERIE BLVD E
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13224-1431
Practice Address - Country:US
Practice Address - Phone:315-445-2678
Practice Address - Fax:315-445-2838
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049454-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice