Provider Demographics
NPI:1750447843
Name:VASA, DINESH
Entity Type:Individual
Prefix:DR
First Name:DINESH
Middle Name:
Last Name:VASA
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 1:257 NASSAU RD
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1736
Mailing Address - Country:US
Mailing Address - Phone:516-334-1076
Mailing Address - Fax:516-334-1076
Practice Address - Street 1:257 NASSAU RD
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1736
Practice Address - Country:US
Practice Address - Phone:516-334-1076
Practice Address - Fax:516-334-1076
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0355001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00520163Medicaid