Provider Demographics
NPI:1700918596
Name:VASSALLO, CALOGERO (DDS)
Entity Type:Individual
Prefix:DR
First Name:CALOGERO
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NESCONSET HWY
Mailing Address - Street 2:BUILDING 19-B
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2555
Mailing Address - Country:US
Mailing Address - Phone:631-265-3656
Mailing Address - Fax:
Practice Address - Street 1:2500 NESCONSET HWY
Practice Address - Street 2:BUILDING 19-B
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2555
Practice Address - Country:US
Practice Address - Phone:631-265-3656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0506361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161750869OtherTAX ID#