Provider Demographics
NPI:1548313323
Name:D ANGELO, KEVIN AUGUST (DDS)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:AUGUST
Last Name:D ANGELO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 ABBOTT RD
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-2057
Mailing Address - Country:US
Mailing Address - Phone:716-825-5020
Mailing Address - Fax:716-823-7115
Practice Address - Street 1:1497 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-2057
Practice Address - Country:US
Practice Address - Phone:716-825-5020
Practice Address - Fax:716-823-7115
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35876-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00858017Medicaid