Provider Demographics
NPI:1770764169
Name:CANNISTRACI, LAURA R (DDS)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:R
Last Name:CANNISTRACI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 MAIN ST.
Mailing Address - Street 2:SUITE 404
Mailing Address - City:MT. KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549
Mailing Address - Country:US
Mailing Address - Phone:914-666-0084
Mailing Address - Fax:
Practice Address - Street 1:344 MAIN ST.
Practice Address - Street 2:SUITE 404
Practice Address - City:MT. KISCO
Practice Address - State:NY
Practice Address - Zip Code:10549
Practice Address - Country:US
Practice Address - Phone:914-666-0084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039863-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics