Healthcare Provider Details

I. General information

NPI: 1316947476
Provider Name (Legal Business Name): CONSOLACION SOBERANO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 ROCKAWAY BEACH BLVD
ARVERNE NY
11692-1271
US

IV. Provider business mailing address

19 PEPPER CIR E
MASSAPEQUA NY
11758-3509
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax: 718-327-8336
Mailing address:
  • Phone: 718-945-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number045753
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: