Provider Demographics
NPI:1376064378
Name:CAPOGNA, MICHAEL JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOHN
Last Name:CAPOGNA
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 1:1023 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2118
Mailing Address - Country:US
Mailing Address - Phone:516-448-6814
Mailing Address - Fax:
Practice Address - Street 1:1023 N BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2118
Practice Address - Country:US
Practice Address - Phone:516-448-6814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0591171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty