Provider Demographics
NPI:1780874016
Name:CONSOLO, DEMETRIOS LOUIS
Entity type:Individual
Prefix:MR
First Name:DEMETRIOS
Middle Name:LOUIS
Last Name:CONSOLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 WATERFORD RD
Mailing Address - Street 2:
Mailing Address - City:WALWORTH
Mailing Address - State:NY
Mailing Address - Zip Code:14568-9424
Mailing Address - Country:US
Mailing Address - Phone:909-434-5129
Mailing Address - Fax:
Practice Address - Street 1:400 FORT HILL AVE
Practice Address - Street 2:DENTAL DEPT
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1159
Practice Address - Country:US
Practice Address - Phone:585-393-7172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant