Provider Demographics
NPI:1184767873
Name:MASTERSON, JOHN MICHAEL JR (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:MASTERSON
Suffix:JR
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 1:45 WATERFORD WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-9750
Mailing Address - Country:US
Mailing Address - Phone:585-223-3149
Mailing Address - Fax:
Practice Address - Street 1:402 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NY
Practice Address - Zip Code:14522-1004
Practice Address - Country:US
Practice Address - Phone:315-597-4581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032505-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice