Provider Demographics
NPI:1740438787
Name:DOMENICK F. D'ANGELICA
Entity type:Organization
Organization Name:DOMENICK F. D'ANGELICA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOMENICK
Authorized Official - Middle Name:F
Authorized Official - Last Name:D'ANGELICA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-671-0480
Mailing Address - Street 1:1425 E GUN HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3066
Mailing Address - Country:US
Mailing Address - Phone:718-671-0480
Mailing Address - Fax:
Practice Address - Street 1:1425 E GUN HILL RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3066
Practice Address - Country:US
Practice Address - Phone:718-671-0480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01005141Medicaid