Healthcare Provider Details

I. General information

NPI: 1477624989
Provider Name (Legal Business Name): ANTONIO L DEL VALLE DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 12/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 W 54TH ST #1E
NEW YORK NY
10019-5404
US

IV. Provider business mailing address

135 E 50TH ST #5E
NEW YORK NY
10022-7504
US

V. Phone/Fax

Practice location:
  • Phone: 212-245-5801
  • Fax: 212-977-9648
Mailing address:
  • Phone: 917-450-6531
  • Fax: 212-213-3589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20681
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number251014
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number048825-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: