MEDICARE: STATEN ISLAND SMILE DENTAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	0555071	NY

General Provider Information

NPI Number	:	1639622020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEN ISLAND SMILE DENTAL PLLC

Provider Business Mailing Address
First Line	:	621 KATAN AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-3422
Country	:	US
Telephone Number	:	718-948-4000
Fax Number	:	718-948-4001

Provider Business Practice Location Address
First Line	:	621 KATAN AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-3422
Country	:	US
Telephone Number	:	718-948-4000
Fax Number	:	718-948-4001

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. ROCCO DIANTONIO
Credential	:	DDS
Telephone Number	:	718-948-4000

Provider Enumeration Date	:	08/02/2016
Last Update Date	:	08/02/2016

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