Healthcare Provider Details

I. General information

NPI: 1376542498
Provider Name (Legal Business Name): CARLO IZZO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/18/2006
Reactivation Date: 03/29/2006

III. Provider practice location address

144 LAKEVIEW AVE
LYNBROOK NY
11563-1755
US

IV. Provider business mailing address

144 LAKEVIEW AVE
LYNBROOK NY
11563-1755
US

V. Phone/Fax

Practice location:
  • Phone: 516-887-1199
  • Fax: 516-887-1199
Mailing address:
  • Phone: 516-887-1199
  • Fax: 516-887-4043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0452341
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: