Provider Demographics
NPI:1639622020
Name:STATEN ISLAND SMILE DENTAL PLLC
Entity Type:Organization
Organization Name:STATEN ISLAND SMILE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROCCO
Authorized Official - Middle Name:
Authorized Official - Last Name:DIANTONIO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-948-4000
Mailing Address - Street 1:621 KATAN AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-3422
Mailing Address - Country:US
Mailing Address - Phone:718-948-4000
Mailing Address - Fax:718-948-4001
Practice Address - Street 1:621 KATAN AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-3422
Practice Address - Country:US
Practice Address - Phone:718-948-4000
Practice Address - Fax:718-948-4001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05550711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty