Provider Demographics
NPI:1295311371
Name:WASACZ, COLIN J (DMD)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:J
Last Name:WASACZ
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 1:1044 STATE ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12307-1508
Mailing Address - Country:US
Mailing Address - Phone:518-370-1441
Mailing Address - Fax:518-395-9431
Practice Address - Street 1:1044 STATE ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12307-1508
Practice Address - Country:US
Practice Address - Phone:518-370-1441
Practice Address - Fax:518-395-9431
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062612122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY331833OtherOSCAR
NY02995513Medicaid
53099AOtherMEDICARE PIN