Provider Demographics
NPI:1851956668
Name:CALABRESE, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CALABRESE
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 1:64 HIGH MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-1663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 N MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1834
Practice Address - Country:US
Practice Address - Phone:413-224-1493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN1858608122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program