Healthcare Provider Details

I. General information

NPI: 1760554950
Provider Name (Legal Business Name): CHARLES J VALICENTI DR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 BAYVILLE AVE
BAYVILLE NY
11709
US

IV. Provider business mailing address

242 BAYVILLE AVE
BAYVILLE NY
11709
US

V. Phone/Fax

Practice location:
  • Phone: 516-628-1122
  • Fax: 516-628-2881
Mailing address:
  • Phone: 516-628-1122
  • Fax: 516-628-2881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number032785
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number39040
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number049785
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: