Provider Demographics
NPI:1790817716
Name:VASSALLO, MICHAEL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E 60TH ST
Mailing Address - Street 2:10C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1117
Mailing Address - Country:US
Mailing Address - Phone:212-832-8966
Mailing Address - Fax:212-355-7609
Practice Address - Street 1:121 E 60TH ST
Practice Address - Street 2:10C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1117
Practice Address - Country:US
Practice Address - Phone:212-832-8966
Practice Address - Fax:212-355-7609
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0414681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice