MEDICARE: DR. CHARLES J VALICENTI DR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	032785	NY
2	122300000X	Dentist	39040	NY
3	122300000X	Dentist	049785	NY

General Provider Information

NPI Number	:	1760554950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES J VALICENTI DR

Provider Business Mailing Address
First Line	:	242 BAYVILLE AVE
Second Line	:
City	:	BAYVILLE
State	:	NY
Zip	:	11709
Country	:	US
Telephone Number	:	516-628-1122
Fax Number	:	516-628-2881

Provider Business Practice Location Address
First Line	:	242 BAYVILLE AVE
Second Line	:
City	:	BAYVILLE
State	:	NY
Zip	:	11709
Country	:	US
Telephone Number	:	516-628-1122
Fax Number	:	516-628-2881

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	07/08/2007

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