Provider Demographics
NPI:1447248364
Name:MASTRODOMENICO, JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:MASTRODOMENICO
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 1:258 E MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2456
Mailing Address - Country:US
Mailing Address - Phone:516-222-1001
Mailing Address - Fax:516-794-5902
Practice Address - Street 1:258 E MEADOW AVE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2456
Practice Address - Country:US
Practice Address - Phone:516-222-1001
Practice Address - Fax:516-794-5902
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0435701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice