Healthcare Provider Details

I. General information

NPI: 1184701252
Provider Name (Legal Business Name): LEO R CACCIOTTI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E BUFFALO ST 204
ITHACA NY
14850-4258
US

IV. Provider business mailing address

303 SAINT CATHERINES CIR
ITHACA NY
14850-1724
US

V. Phone/Fax

Practice location:
  • Phone: 607-277-5498
  • Fax:
Mailing address:
  • Phone: 607-257-4457
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number026328
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: