Provider Demographics
NPI:1710415039
Name:DE LOS SANTOS, ABNER O
Entity Type:Individual
Prefix:
First Name:ABNER
Middle Name:O
Last Name:DE LOS SANTOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 FAIRPORT VILLAGE LNDG
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-1804
Mailing Address - Country:US
Mailing Address - Phone:585-223-5480
Mailing Address - Fax:585-223-5480
Practice Address - Street 1:124 FAIRPORT VILLAGE LNDG
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1804
Practice Address - Country:US
Practice Address - Phone:585-223-5480
Practice Address - Fax:585-228-9459
Is Sole Proprietor?:No
Enumeration Date:2017-05-31
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0601481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice