Provider Demographics
NPI:1710912274
Name:DIVITA, CARL LOUIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:LOUIS
Last Name:DIVITA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2800 SPENCERPORT RD.
Mailing Address - Street 2:SUITE A4
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559-2180
Mailing Address - Country:US
Mailing Address - Phone:585-352-3627
Mailing Address - Fax:585-352-1678
Practice Address - Street 1:2800 SPENCERPORT ROAD
Practice Address - Street 2:A4
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-2180
Practice Address - Country:US
Practice Address - Phone:585-352-3627
Practice Address - Fax:585-352-1678
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY027463-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry