Healthcare Provider Details

I. General information

NPI: 1184702797
Provider Name (Legal Business Name): LOUIS COLACICCO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 BROADHOLLOW RD
MELVILLE NY
11747-4713
US

IV. Provider business mailing address

425 BROADHOLLOW RD
MELVILLE NY
11747-4713
US

V. Phone/Fax

Practice location:
  • Phone: 631-752-1033
  • Fax: 631-752-1034
Mailing address:
  • Phone: 631-752-1033
  • Fax: 631-752-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number035856
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: