Provider Demographics
NPI:1780602920
Name:MISTRETTA, MICHAEL CHARLES (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:MISTRETTA
Suffix:
Gender:
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 1:200 CENTRAL PARK S
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1436
Mailing Address - Country:US
Mailing Address - Phone:212-245-3292
Mailing Address - Fax:212-245-8758
Practice Address - Street 1:200 CENTRAL PARK S
Practice Address - Street 2:SUITE 105
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1436
Practice Address - Country:US
Practice Address - Phone:212-245-3292
Practice Address - Fax:212-245-8758
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049087-11223S0112X
NY240428-1204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery