Provider Demographics
NPI:1851596555
Name:CARDOSO, ANDRE T (DMD, MD)
Entity Type:Individual
Prefix:
First Name:ANDRE
Middle Name:T
Last Name:CARDOSO
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4322 KELSEY DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13215-1256
Mailing Address - Country:US
Mailing Address - Phone:917-692-6301
Mailing Address - Fax:
Practice Address - Street 1:7334 BUCKLEY RD
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-2600
Practice Address - Country:US
Practice Address - Phone:315-458-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0502991223S0112X
NY241657204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery