Provider Demographics
NPI:1477624989
Name:DEL VALLE, ANTONIO L (DMD, MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:L
Last Name:DEL VALLE
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E 50TH ST
Mailing Address - Street 2:#5E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-7504
Mailing Address - Country:US
Mailing Address - Phone:917-450-6531
Mailing Address - Fax:212-213-3589
Practice Address - Street 1:45 W 54TH ST
Practice Address - Street 2:#1E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-5404
Practice Address - Country:US
Practice Address - Phone:212-245-5801
Practice Address - Fax:212-977-9648
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ206811223S0112X
NY251014204E00000X
NY048825-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02083594Medicaid