Healthcare Provider Details

I. General information

NPI: 1174957641
Provider Name (Legal Business Name): GREGORY MICHAEL VALLECORSA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2013
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 SUNSET DR
LATHAM NY
12110-2104
US

IV. Provider business mailing address

24 CAVALIER WAY
LATHAM NY
12110-1998
US

V. Phone/Fax

Practice location:
  • Phone: 518-785-5100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number057400-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: