Provider Demographics
NPI:1457508897
Name:PERRY M. IACOVETTI DDS PC
Entity Type:Organization
Organization Name:PERRY M. IACOVETTI DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:IACOVETTI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-224-0040
Mailing Address - Street 1:5231 LITTLE NECK PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1836
Mailing Address - Country:US
Mailing Address - Phone:718-224-0040
Mailing Address - Fax:
Practice Address - Street 1:5231 LITTLE NECK PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1836
Practice Address - Country:US
Practice Address - Phone:718-224-0040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0508821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02768981Medicaid