Provider Demographics
NPI:1912904020
Name:BELLUSCIO, MICHAEL PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:PETER
Last Name:BELLUSCIO
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 1:1003 LONI DR
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2347
Mailing Address - Country:US
Mailing Address - Phone:707-725-6918
Mailing Address - Fax:707-725-0551
Practice Address - Street 1:1003 LONI DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2347
Practice Address - Country:US
Practice Address - Phone:707-725-6918
Practice Address - Fax:707-725-0551
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0295581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice