Provider Demographics
NPI:1134492945
Name:DAMICO, MICHAEL DOMENICK
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DOMENICK
Last Name:DAMICO
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 1:222 E MAIN ST
Mailing Address - Street 2:STE 316
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2814
Mailing Address - Country:US
Mailing Address - Phone:631-724-4747
Mailing Address - Fax:631-780-6528
Practice Address - Street 1:222 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 316
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2871
Practice Address - Country:US
Practice Address - Phone:631-724-4747
Practice Address - Fax:631-780-6528
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043141122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBD5046405OtherDEA NUMBER