Provider Demographics
NPI:1073653028
Name:DEANGELO, JOHN
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:DEANGELO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1603
Mailing Address - Country:US
Mailing Address - Phone:585-424-1111
Mailing Address - Fax:585-424-1110
Practice Address - Street 1:369 WHITE SPRUCE BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1603
Practice Address - Country:US
Practice Address - Phone:585-424-1111
Practice Address - Fax:585-424-1110
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034261-11223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics