Provider Demographics
NPI:1326057845
Name:RISOTTO, THOMAS JOHN SR (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:RISOTTO
Suffix:SR
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 1:369 E MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2800
Mailing Address - Country:US
Mailing Address - Phone:631-277-5566
Mailing Address - Fax:631-277-8690
Practice Address - Street 1:369 E MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2800
Practice Address - Country:US
Practice Address - Phone:631-277-5566
Practice Address - Fax:631-277-8690
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029152122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00626848Medicaid