Provider Demographics
NPI:1164688057
Name:DALESSIO, LARA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:
Last Name:DALESSIO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 TUXEDO AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-2644
Mailing Address - Country:US
Mailing Address - Phone:973-777-0848
Mailing Address - Fax:973-777-0898
Practice Address - Street 1:521 VAN HOUTEN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2190
Practice Address - Country:US
Practice Address - Phone:973-949-4523
Practice Address - Fax:973-949-4523
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102381700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist