MEDICARE: ANNA VASSALLO DMD

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	122300000X	Dentist	14710	NC

General Provider Information

NPI Number	:	1689510976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA VASSALLO DMD

Provider Business Mailing Address
First Line	:	9425 DELEGATES ROW
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-3805
Country	:	US
Telephone Number	:	317-255-6800
Fax Number	:

Provider Business Practice Location Address
First Line	:	908 N US HIGHWAY 421
Second Line	:
City	:	CLINTON
State	:	NC
Zip	:	28328-0410
Country	:	US
Telephone Number	:	910-299-0991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2026
Last Update Date	:	06/04/2026

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