Provider Demographics
NPI:1619173978
Name:COLARUSSO, ANTHONY CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:CHARLES
Last Name:COLARUSSO
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:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:PLEASANT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:12569-0655
Mailing Address - Country:US
Mailing Address - Phone:845-635-3811
Mailing Address - Fax:845-635-8392
Practice Address - Street 1:1577 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PLEASANT VALLEY
Practice Address - State:NY
Practice Address - Zip Code:12569
Practice Address - Country:US
Practice Address - Phone:845-635-3811
Practice Address - Fax:845-635-8392
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0417291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice