Healthcare Provider Details

I. General information

NPI: 1790016103
Provider Name (Legal Business Name): JOSEPH L. DISANO D.M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2010
Last Update Date: 01/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 MAIN ST
WAKEFIELD RI
02879-7407
US

IV. Provider business mailing address

390 MAIN ST
WAKEFIELD RI
02879-7407
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-8693
  • Fax: 401-788-9438
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2746
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1457
License Number StateRI

VIII. Authorized Official

Name: DR. JOSEPH L DISANO
Title or Position: OWNER
Credential: D.M.D.
Phone: 401-789-8693