Provider Demographics
NPI:1144333295
Name:IACOVETTI, PERRY M (DDS)
Entity type:Individual
Prefix:DR
First Name:PERRY
Middle Name:M
Last Name:IACOVETTI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5231 LITTLE NECK PKWY
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1836
Mailing Address - Country:US
Mailing Address - Phone:718-224-0040
Mailing Address - Fax:
Practice Address - Street 1:5231 LITTLE NECK PKWY
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-1836
Practice Address - Country:US
Practice Address - Phone:718-224-0040
Practice Address - Fax:718-224-8853
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0508821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02768981Medicaid