Healthcare Provider Details

I. General information

NPI: 1245317163
Provider Name (Legal Business Name): JOHN MICHAEL CAPOGNA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 B NORTH BROADWAY
NORTH MASSAPEQUA NY
11758
US

IV. Provider business mailing address

1129 B NORTH BROADWAY
NORTH MASSAPEQUA NY
11758
US

V. Phone/Fax

Practice location:
  • Phone: 516-752-9060
  • Fax: 516-752-1432
Mailing address:
  • Phone: 516-752-9060
  • Fax: 516-752-1432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number039309-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: