=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174836274
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VINCENT JAMES BILELLO D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2010
-----------------------------------------------------
Last Update Date | 07/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6534 MYRTLE AVE
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-6212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-386-8728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 KNICKERBOCKER RD
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-3405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-353-9980
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 50 052908
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------