=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811108277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROSARIO ANTONIO DE VITO D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2007
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 220 E 57TH ST SUITE 2BC
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-2805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-751-6344
-----------------------------------------------------
Fax | 212-751-8458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 E 57TH ST SUITE 2BC
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10022-2805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-751-6344
-----------------------------------------------------
Fax | 212-751-8458
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 046718
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------