Provider Demographics
NPI:1174652994
Name:TISO, CARMINE L (DDS)
Entity Type:Individual
Prefix:
First Name:CARMINE
Middle Name:L
Last Name:TISO
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 1:9530 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031
Mailing Address - Country:US
Mailing Address - Phone:716-759-2255
Mailing Address - Fax:716-759-1318
Practice Address - Street 1:9530 MAIN ST
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031
Practice Address - Country:US
Practice Address - Phone:716-759-2255
Practice Address - Fax:716-759-1318
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036870122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4000196OtherINDEPENDENT HEALTH
NY00072046001OtherBLUE CROSS SHIELD
NY00072046001OtherBLUE CROSS SHIELD