MEDICARE: QDG DENTAL, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	054188	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447709761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QDG DENTAL, PC

Provider Business Mailing Address
First Line	:	13107 40TH RD
Second Line	:	E30
City	:	FLUSHING
State	:	NY
Zip	:	11354-5116
Country	:	US
Telephone Number	:	718-353-3332
Fax Number	:

Provider Business Practice Location Address
First Line	:	13107 40TH RD
Second Line	:	E30
City	:	FLUSHING
State	:	NY
Zip	:	11354-5116
Country	:	US
Telephone Number	:	718-353-3332
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	QIAO GUO
Credential	:	DDS
Telephone Number	:	646-248-2946

Provider Enumeration Date	:	09/28/2016
Last Update Date	:	09/28/2016

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