Provider Demographics
NPI:1942393905
Name:SANGIACOMO, THOMAS ROBERT (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ROBERT
Last Name:SANGIACOMO
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 1:102 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:NY
Mailing Address - Zip Code:13045-1208
Mailing Address - Country:US
Mailing Address - Phone:607-753-0011
Mailing Address - Fax:607-753-0573
Practice Address - Street 1:102 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1208
Practice Address - Country:US
Practice Address - Phone:607-753-0011
Practice Address - Fax:607-753-0573
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050341-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02608097Medicaid
NYRA9124Medicare ID - Type Unspecified
NYT92561Medicare UPIN