Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 036942 | NY |
NPI | 1033222328 |
---|---|
Provider Name | Dr. Dominic A Colarusso JR. |
First Address | Olean, NY 14760-1609 |
Second Address | Olean, NY 14760-2504 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2006 |
Last Update Date | 08/07/2007 |