Provider Demographics
NPI:1699876730
Name:MENDICINO, ANTHONY J (DDS)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:MENDICINO
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:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-0423
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:6692 MIDDLE RD
Practice Address - Street 2:SUITE 2100
Practice Address - City:SODUS
Practice Address - State:NY
Practice Address - Zip Code:14551-9602
Practice Address - Country:US
Practice Address - Phone:315-483-1199
Practice Address - Fax:315-483-2451
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY70503GHOtherEXCELLUS GENEVA SITE
NY02562825Medicaid
NY70461FLOtherEXCELLUS SODUS SITE