Provider Demographics
NPI:1548552789
Name:DEFEO, ROBERT C (DDS)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:DEFEO
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 1:5454 MERRICK RD
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6213
Mailing Address - Country:US
Mailing Address - Phone:516-798-3300
Mailing Address - Fax:
Practice Address - Street 1:5454 MERRICK RD
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6213
Practice Address - Country:US
Practice Address - Phone:516-798-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-06
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0370471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice