Provider Demographics
NPI:1558403618
Name:DICOSIMO, CHARLES JOHN II (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:JOHN
Last Name:DICOSIMO
Suffix:II
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Mailing Address - Street 1:8415 HOBNAIL RD
Mailing Address - Street 2:
Mailing Address - City:MANLIUS
Mailing Address - State:NY
Mailing Address - Zip Code:13104-9332
Mailing Address - Country:US
Mailing Address - Phone:315-682-2622
Mailing Address - Fax:
Practice Address - Street 1:407 UNIVERSITY AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1866
Practice Address - Country:US
Practice Address - Phone:315-472-4514
Practice Address - Fax:315-475-6896
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY0327461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery