Provider Demographics
NPI:1376683714
Name:CALDERON, MIKE E (DDS)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:E
Last Name:CALDERON
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 1:720 MONTAUK HWY
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-4411
Mailing Address - Country:US
Mailing Address - Phone:631-666-1392
Mailing Address - Fax:631-666-1520
Practice Address - Street 1:720 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4411
Practice Address - Country:US
Practice Address - Phone:631-666-1392
Practice Address - Fax:631-666-1520
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045 794122300000X
NY0457941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02168867Medicaid