Provider Demographics
NPI:1639193584
Name:EVANGELISTA, SANDRO (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANDRO
Middle Name:
Last Name:EVANGELISTA
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 1:494 ROUTE 299
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-2833
Mailing Address - Country:US
Mailing Address - Phone:845-691-5600
Mailing Address - Fax:845-691-8633
Practice Address - Street 1:494 ROUTE 299
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-2833
Practice Address - Country:US
Practice Address - Phone:845-691-5600
Practice Address - Fax:845-691-8633
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0455721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice