Provider Demographics
NPI:1659556660
Name:SANZONE, KELLIE A
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:A
Last Name:SANZONE
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 1:1114 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4353
Mailing Address - Country:US
Mailing Address - Phone:315-788-0122
Mailing Address - Fax:
Practice Address - Street 1:1114 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4353
Practice Address - Country:US
Practice Address - Phone:315-788-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0412791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics