Provider Demographics
NPI:1639133978
Name:COLOSIMO, VINCENT (DMD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:COLOSIMO
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 1:926 GREAT POND DR
Mailing Address - Street 2:SUITE 2003
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7244
Mailing Address - Country:US
Mailing Address - Phone:407-772-5124
Mailing Address - Fax:407-788-3572
Practice Address - Street 1:2811 N GREEN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-0401
Practice Address - Country:US
Practice Address - Phone:702-434-2219
Practice Address - Fax:702-456-6160
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4547T1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510914OtherRENO OFFICE MEDICAID#
NV100511623OtherTROPICAL PKWY OFFICE MEDICAID#
NV100511625OtherNELLIS BLVD OFFICE MEDICAID#
NV100511624OtherSMOKE RANCH RD OFFICE MEDICAID#
NV100507579OtherHENDERSON OFFICE MEDICAID#
NV100511622OtherSPARKS OFFICE MEDICAID#
PA001264970Medicaid
NV100511621OtherCARSON CITY OFFICE MEDICAID#