Healthcare Provider Details

I. General information

NPI: 1750379699
Provider Name (Legal Business Name): STEVEN R IZZO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6853 FRESH POND RD
RIDGEWOOD NY
11385-5263
US

IV. Provider business mailing address

6853 FRESH POND RD
RIDGEWOOD NY
11385-5263
US

V. Phone/Fax

Practice location:
  • Phone: 718-821-2545
  • Fax: 718-418-2809
Mailing address:
  • Phone: 718-821-2545
  • Fax: 718-418-2809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number042245
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: