Healthcare Provider Details

I. General information

NPI: 1770764169
Provider Name (Legal Business Name): LAURA R. CANNISTRACI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

344 MAIN ST. SUITE 404
MT. KISCO NY
10549
US

IV. Provider business mailing address

344 MAIN ST. SUITE 404
MT. KISCO NY
10549
US

V. Phone/Fax

Practice location:
  • Phone: 914-666-0084
  • Fax:
Mailing address:
  • Phone: 914-666-0084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number039863-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: