Provider Demographics
NPI:1750379699
Name:IZZO, STEVEN R (DDS)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:R
Last Name:IZZO
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 1:6853 FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-5263
Mailing Address - Country:US
Mailing Address - Phone:718-821-2545
Mailing Address - Fax:718-418-2809
Practice Address - Street 1:6853 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5263
Practice Address - Country:US
Practice Address - Phone:718-821-2545
Practice Address - Fax:718-418-2809
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0422451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01594536Medicaid