Healthcare Provider Details

I. General information

NPI: 1689682684
Provider Name (Legal Business Name): LUCY VILLA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 OVINGTON AVE STE 101
BROOKLYN NY
11209
US

IV. Provider business mailing address

355 OVINGTON AVE STE 101
BROOKLYN NY
11209
US

V. Phone/Fax

Practice location:
  • Phone: 718-285-6039
  • Fax: 718-285-3518
Mailing address:
  • Phone: 718-285-6039
  • Fax: 718-285-3518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDI020208
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9118
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number0493291
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: