Provider Demographics
NPI:1811005705
Name:MAZZOLA, PHILIP VINCENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:VINCENT
Last Name:MAZZOLA
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 1:280 SMITHTOWN BLVD
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-2054
Mailing Address - Country:US
Mailing Address - Phone:631-588-6754
Mailing Address - Fax:631-588-1822
Practice Address - Street 1:280 SMITHTOWN BLVD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-2054
Practice Address - Country:US
Practice Address - Phone:631-588-6754
Practice Address - Fax:631-588-1822
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030876122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist