Provider Demographics
NPI:1821613464
Name:VALLECORSA, JONATHAN DAVID
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DAVID
Last Name:VALLECORSA
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 1:4 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2104
Mailing Address - Country:US
Mailing Address - Phone:518-785-5100
Mailing Address - Fax:
Practice Address - Street 1:4 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2104
Practice Address - Country:US
Practice Address - Phone:518-785-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist