Provider Demographics
NPI:1174957641
Name:VALLECORSA, GREGORY MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:MICHAEL
Last Name:VALLECORSA
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 1:24 CAVALIER WAY
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2104
Practice Address - Country:US
Practice Address - Phone:518-785-5100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-02
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY057400-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program