Provider Demographics
NPI:1659585248
Name:DIBENEDETTO, MAURO V (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAURO
Middle Name:V
Last Name:DIBENEDETTO
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 1:800 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4917
Mailing Address - Country:US
Mailing Address - Phone:631-244-5724
Mailing Address - Fax:631-244-5734
Practice Address - Street 1:800 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4917
Practice Address - Country:US
Practice Address - Phone:631-244-5724
Practice Address - Fax:631-244-5734
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043792-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice