=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962655209
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEVEN R IZZO DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2008
-----------------------------------------------------
Last Update Date | 11/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6853 FRESH POND RD
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-5263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-821-2545
-----------------------------------------------------
Fax | 718-418-2809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6853 FRESH POND RD
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-5263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-821-2545
-----------------------------------------------------
Fax | 718-418-2809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEVEN R IZZO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 718-821-2545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 042245
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------