Provider Demographics
NPI:1205050275
Name:COPPOLA, MICHAEL A (DMD PC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:COPPOLA
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3720 SOUTH PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:BLASDELL
Mailing Address - State:NY
Mailing Address - Zip Code:14219
Mailing Address - Country:US
Mailing Address - Phone:716-822-1118
Mailing Address - Fax:716-822-1119
Practice Address - Street 1:3720 SOUTH PARK AVENUE
Practice Address - Street 2:
Practice Address - City:BLASDELL
Practice Address - State:NY
Practice Address - Zip Code:14219
Practice Address - Country:US
Practice Address - Phone:716-822-1118
Practice Address - Fax:716-822-1119
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY041223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist