Provider Demographics
NPI:1639336761
Name:POLICASTRO, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:POLICASTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 ROUTE 25A STE 1
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-7911
Mailing Address - Country:US
Mailing Address - Phone:631-744-3088
Mailing Address - Fax:631-744-3099
Practice Address - Street 1:347 ROUTE 25A STE 1
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-7911
Practice Address - Country:US
Practice Address - Phone:631-744-3088
Practice Address - Fax:631-744-3099
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0523421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice