Provider Demographics
NPI:1467880617
Name:MARICONDO, DAVID JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JAMES
Last Name:MARICONDO
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 1:26546 SAN TORINI RD
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-6101
Mailing Address - Country:US
Mailing Address - Phone:949-367-1882
Mailing Address - Fax:
Practice Address - Street 1:137 STATE ROUTE 104
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2937
Practice Address - Country:US
Practice Address - Phone:315-326-1197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-25
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056680-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist