Provider Demographics
NPI:1891843074
Name:DERICCO, SALVATORE P (DDS)
Entity Type:Individual
Prefix:DR
First Name:SALVATORE
Middle Name:P
Last Name:DERICCO
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 1:141 UNDERHILL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2539
Mailing Address - Country:US
Mailing Address - Phone:914-948-7616
Mailing Address - Fax:
Practice Address - Street 1:141 UNDERHILL AVE
Practice Address - Street 2:
Practice Address - City:WEST HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10604-2539
Practice Address - Country:US
Practice Address - Phone:914-948-7616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0414811223X0400X
CT72921223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics