Provider Demographics
NPI:1902368368
Name:CONSALVO, VANCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:VANCE
Middle Name:
Last Name:CONSALVO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 MEORE WAY
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992-1811
Mailing Address - Country:US
Mailing Address - Phone:845-496-1736
Mailing Address - Fax:
Practice Address - Street 1:2134 STATE ROUTE 208
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:NY
Practice Address - Zip Code:12549-2613
Practice Address - Country:US
Practice Address - Phone:845-457-5763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY061264122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty