Provider Demographics
NPI:1932100161
Name:DETOLLA, PETER J (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:J
Last Name:DETOLLA
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 1:105 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3169
Mailing Address - Country:US
Mailing Address - Phone:631-757-5075
Mailing Address - Fax:
Practice Address - Street 1:58 CHURCH RD
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:NY
Practice Address - Zip Code:11756-2232
Practice Address - Country:US
Practice Address - Phone:516-735-1234
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047832-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice