Provider Demographics
NPI:1467574178
Name:CAMESANO, THEODORE MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:MICHAEL
Last Name:CAMESANO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BUSINESS PARK CT
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-6308
Mailing Address - Country:US
Mailing Address - Phone:315-732-6719
Mailing Address - Fax:315-738-7140
Practice Address - Street 1:8 BUSINESS PARK CT
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-6308
Practice Address - Country:US
Practice Address - Phone:315-732-6719
Practice Address - Fax:315-738-7140
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0306381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00596561Medicaid