Provider Demographics
NPI:1295898286
Name:DESANTIS, JAMES LEONARD (DDS & MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:LEONARD
Last Name:DESANTIS
Suffix:
Gender:M
Credentials:DDS & MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 COLUMBIA DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-3302
Mailing Address - Country:US
Mailing Address - Phone:607-729-5900
Mailing Address - Fax:607-729-6500
Practice Address - Street 1:535 COLUMBIA DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:607-729-5900
Practice Address - Fax:607-729-6500
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0485261223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02395297Medicaid
NY02395297Medicaid