Provider Demographics
NPI:1962655209
Name:STEVEN R IZZO DDS PC
Entity Type:Organization
Organization Name:STEVEN R IZZO DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:IZZO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-821-2545
Mailing Address - Street 1:6853 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5263
Mailing Address - Country:US
Mailing Address - Phone:718-821-2545
Mailing Address - Fax:718-418-2809
Practice Address - Street 1:6853 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5263
Practice Address - Country:US
Practice Address - Phone:718-821-2545
Practice Address - Fax:718-418-2809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-30
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0422451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01594536Medicaid