Provider Demographics
NPI:1386655249
Name:DISABATINO, MARIO P (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:P
Last Name:DISABATINO
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 1:17 W GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:DE
Mailing Address - Zip Code:19977-1106
Mailing Address - Country:US
Mailing Address - Phone:302-653-5011
Mailing Address - Fax:302-653-8839
Practice Address - Street 1:17 W GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:DE
Practice Address - Zip Code:19977-1106
Practice Address - Country:US
Practice Address - Phone:302-653-5011
Practice Address - Fax:302-653-8839
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00007611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice