=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407870744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN MICHAEL IACONO D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45 ORCHARD ST
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-1928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-627-0362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 169 EAKINS RD
-----------------------------------------------------
City | MANHASSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11030-2635
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-365-8810
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 024958
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------