Healthcare Provider Details

I. General information

NPI: 1033222328
Provider Name (Legal Business Name): DOMINIC A COLARUSSO JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 N 3RD ST
OLEAN NY
14760-2504
US

IV. Provider business mailing address

1229 HIGHLAND TER
OLEAN NY
14760-1609
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-8017
  • Fax: 716-372-6931
Mailing address:
  • Phone: 716-373-2743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number036942
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: